BSGE Pelvic Pain Questionnaire
Full Name
Required
Hospital Number (if known)
NHS Number (if known)
Email Address (by completing this field you consent for the Trust contacting you via email)
Background Details
Smoking
** None Smoker Ex smoker Never smoked
What is your height? (in metres)
What is your current weight? (kilograms)
General Questions About Your Pain
Over the course of your current normal menstrual cycle , which of the following symptoms do you experience? Please tick yes or no to show whether you experience symptom during a normal cycle, and then if you have experienced the symptom, circle a score from 1 to 10 to indicate how slight or severe it usually is.
Do you experience pre-menstrual pain (pain before periods)? If yes, please rate your pain 1 (being experienced slightly) to 10 (being experienced severely)
** None 1 2 3 4 5 6 7 8 9 10
Do you experience menstrual pain (pain during periods)? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)
** None 1 2 3 4 5 6 7 8 9 10
Do you experience non-cyclical pelvic pain (pain throughout the month)? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)
** None 1 2 3 4 5 6 7 8 9 10
Do you experience pain during sexual intercourse? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)
** None 1 2 3 4 5 6 7 8 9 10
Do you experience pain opening bowels during a period? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)
** None 1 2 3 4 5 6 7 8 9 10
Do you experience pain opening your bowels at other times? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)
** None 1 2 3 4 5 6 7 8 9 10
Do experience lower back pain? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)
** None 1 2 3 4 5 6 7 8 9 10
Do you experience bladder pain or pain passing urine? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)
** None 1 2 3 4 5 6 7 8 9 10
Do you have difficulty emptying your bladder? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)
** None 1 2 3 4 5 6 7 8 9 10
Information about Bowel Function
NOTE: (N/A is to be used if you have a stoma)
Do you have frequent bowel movements?
** None Never A little of the time Some of the time Most of the time All of the time N/A
Do you have urgent bowel movements?
** None Never A little of the time Some of the time Most of the time All of the time N/A
Do you have sensation on incomplete emptying of the bowel?
** None Never A little of the time Some of the time Most of the time All of the time N/A
Do you have constipation?
** None Never A little of the time Some of the time Most of the time All of the time N/A
Have you been troubled by blood in the stool around the same time as your period?
** None Never A little of the time Some of the time Most of the time All of the time N/A
Medical therapy
Are you currently taking any of the following treatments? (Please tick to indicate your use)
Oral contraceptive pill
** None Yes No
Mirena IUS (hormone containing coil)
** None Yes No
GnRH Analogues E.g. Goserelin, Buserelin, Lupron, Naferelin
** None Yes No
GnRH Analogues + oestrogens (HRT)
** None Yes No
Progestogens E.g. Primolut, Duphaston, Provera
** None Yes No
Aromatase inhibitors
** None Yes No
Hormone replacement
** None Yes No
Fertility
Are you currently pregnant?
** None No No, but have been trying to get pregnant Yes, been trying for less than 18 months Yes, been trying for more than 18 months
Have you ever had previous surgery for endometriosis
** None Yes, I have had endometriosis surgically treated before today Yes, I have had an ovary removed Yes, I have had both ovaries removed Yes, I have had a hysterectomy
Questions about your health in general
The following questions refer to how you feel about your health in general TODAY. They form part of a standard set of questions relating to quality of life and therefore some may not seem particularly relevant to you. However, please try to answer ALL questions.
Please score how good or bad your health is TODAY. The best health state you can imagine is marked 100 and the worst health state you can imagine is marked 0.
Please indicate which statements best describe your health state TODAY
Usual Activities (e.g. work, study, housework, family or leisure activities)
** None I have no problems with performing my usual activities I have some problems with performing my usual activities I am able to perform my usual activities
Pain / Discomfort
** None I have no pain/discomfort I have moderate pain/discomfort I have extreme pain/discomfort
Anxiety / Depression
** None I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed
Mobility
** None I have no problems in walking about I have some problems in walking about I am confined to bed
Self-care
** None I have no problems with self-care I have some problems washing or dressing myself
Thank you very much for completing this questionnaire.
We would like to reassure you again that all the answers will be treated in the strictest confidence.
