BSGE Pelvic Pain Questionnaire

This questionnaire has been designed to help us understand your problems and to find the most appropriate treatments. It may also help you to formulate your thoughts on your symptoms and the way in which they can affect your quality of life. It is important that you answer as many of the questions as you are able. If you find any of them awkward to answer, please leave them blank and we may discuss them at your consultation should you wish.

Please be assured that the information you provide will be kept confidential, in accordance with Data Protection legislation and entered onto a central database together with the results of clinical examination and any tests that you may have. The findings and results of any surgical intervention that you may have will be recorded and assessed, as will your responses from follow up questionnaires.

The anonymous information collected on all patients will be used for research and study into the treatment of endometriosis, and may be published in medical journals or presented at medical scientific meetings.

If you do not understand any of the questions, particularly about previous treatment, please leave these blank and raise the questions when you are seen in the clinic.

BSGE Pelvic Pain Questionnaire

Full Name Required

Date of Birth

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

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)

Do you experience menstrual pain (pain during periods)? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)

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)

Do you experience pain during sexual intercourse? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)

Do you experience pain opening bowels during a period? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)

Do you experience pain opening your bowels at other times? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)

Do experience lower back pain? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)

Do you experience bladder pain or pain passing urine? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)

Do you have difficulty emptying your bladder? If yes, rate your pain 1 (being experienced slightly) to 10 (being experienced severely)

Information about Bowel Function

NOTE: (N/A is to be used if you have a stoma)

Do you have frequent bowel movements?

Do you have urgent bowel movements?

Do you have sensation on incomplete emptying of the bowel?

Do you have constipation?

Have you been troubled by blood in the stool around the same time as your period?

Fertility

Are you currently pregnant?

Do you take any of the following painkillers

Paracetamol

NSAID anti-inflammatories eg ibuprofen, diclofenac

Opiates eg tramadol, DF118

Have you ever had previous surgery for endometriosis

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)

Pain / Discomfort

Anxiety / Depression

Mobility

Self-care

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.

I agree to the privacy policy.

Patients and Visitors

Fundraising

Cancel/Change an Appointment

Contact form

BSGE Pelvic Pain Questionnaire

BSGE Pelvic Pain Questionnaire

Background Details

General Questions About Your Pain

Information about Bowel Function

Fertility

Questions about your health in general

Please indicate which statements best describe your health state TODAY

Thank you very much for completing this questionnaire.

Address:

Tel:

BSGE Pelvic Pain Questionnaire

BSGE Pelvic Pain Questionnaire

Background Details

General Questions About Your Pain

Information about Bowel Function

Fertility

Questions about your health in general

Please indicate which statements best describe your health state TODAY

Thank you very much for completing this questionnaire.

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