To be printed on headed paper
This questionnaire is designed to help you describe your pain symptoms and your health, and how these impact on your life in general.Please read through the instructions at the beginning of each section carefully. For most questions, all you need to do is tick the appropriate box that best describes how you feel.
There are no right or wrong answers. We are just interested in your own views about your health, your pain symptoms and how you feel about life in general. Try not to dwell too long on any question, and choose the answer that comes closest to how you have been feeling generally.
Please try to answer as many of the questions as possible, even if some may seem repetitive or less relevant. There are some sensitive questions but you can choose to miss out any question you do not feel comfortable answering.
Your doctor or nurse who looks at this may make some extra notes on the blank sections marked for them. If you have any queries about the form, your doctor or nurse will be able to help you with them.
For any symptoms other than pain, be sure to discuss these with the doctor or nurse you are seeing.
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry Page 1 of 15 Version 2.1 - 27th November 2012
1. ABOUT YOUR PAIN PROBLEMS
Please describe your pain problems, with the most troublesome problem first.
1. ______
2.______
3.______
4.______
5.______
What do you think is causing your pain?
______
______
______
______
Since your previous visit, overall has the pain? (please tick one box)
Got a lot worse / Got a little worse / Not changed / Got a little better / Got a lot better / Don’t knowFor approximately how long in total did you have pelvic pain in the last 3 months? (please tick one box)
Less than one day a month /One day a month /
2 – 3 days a month /
One day a week /
More than one day a week /
Every day /
2. ABOUT YOUR PAIN
Please shade areas of pain and write a number from 1 to 10 at the site(s)
of the pain. (10 = most severe pain imaginable
3. ABOUT YOUR PAIN
There are many types of pain. For each of those list below, please circle the number that best describes your average level of pain over the last month. Also say roughly how many months you have had each type of pain.
For example
No Pain / Pain just before period/ Worst pain imaginable / Duration (months)
Now please consider your pain problems. How do you rate your pain, on average?
No Pain / Pain just before period/ Worst pain imaginable / Duration (months)
No Pain / Pain during period
/ Worst pain imaginable / Duration (months)
No Pain / Pain when period is over
/ Worst pain imaginable / Duration (months)
No Pain / Pain mid-cycle
/ Worst pain imaginable / Duration (months)
If you did not have sexual intercourse in the last month, please tick box and skip this section to go to the next page
No Pain / Pain at the point of vaginal penetration
/ Worst pain imaginable / Duration (months)
No Pain / Deep pain during intercourse
/ Worst pain imaginable / Duration (months)
No Pain / Burning vaginal pain during intercourse
/ Worst pain imaginable / Duration (months)
No Pain / Pelvic pain lasting hours or days after
/ Worst pain imaginable / Duration (months)
Other types of pelvic pain in the last month
By ‘Pelvic pain’ we mean any type of pain in the lower part of your belly (in the area from your navel down).
No Pain / Pain when bladder is full/ Worst pain imaginable / Duration (months)
No Pain / Pain with urination
/ Worst pain imaginable / Duration (months)
No Pain / Muscle/joint pain in pelvis
/ Worst pain imaginable / Duration (months)
No Pain / Pain in pelvis when lifting
/ Worst pain imaginable / Duration (months)
No Pain / Pain with sitting
/ Worst pain imaginable / Duration (months)
No Pain / Backache
/ Worst pain imaginable / Duration (months)
No Pain / Migraine headache
/ Worst pain imaginable / Duration (months)
4. DESCRIBING YOUR PAIN
The words below describe average pain. Place a tick () in the box which represents the degree to which you feel that type of pain. Please limit yourself to a description of the pain in your pelvic area only.
What does your pain feel like? / NONE0 / MILD
1 / MODERATE
2 / SEVERE
3
Throbbing / / / /
Shooting / / / /
Stabbing / / / /
Sharp / / / /
Cramping / / / /
Gnawing / / / /
Hot-burning / / / /
Aching / / / /
Heavy / / / /
Tender / / / /
Splitting / / / /
Tiring-exhausting / / / /
Sickening / / / /
Fearful / / / /
Punishing-cruel / / / /
Melzak R. The Short-form McGill Pain Questionnaire. Pain 1987;30:191-197.
5. CURRENT MEDICATION
6. TREATMENTS FOR PAIN
What types of treatments have you tried in the past for your pain? (please indicate with a tick)
No / Yes / If yes, was it helpful? / No / Yes / If yes, was it helpful?No / Yes / No / Yes
Acupuncture / / / / / Massage / / / /
Anti-seizure medications / / / / / Meditation or relaxation exercises / / / /
Antidepressants / / / / / Strong painkillers / / / /
Biofeedback / / / / / Nerve blocks / / / /
Botox injection / / / / / Non-prescription medicine / / / /
Contraceptive pills/patch/ ring / / / / / Nutrition/diet / / / /
Exercise, yoga or pilates / / / / / Physiotherapy / / / /
Hormonal therapy for endometrisosis / / / / / Psychological (talking) therapy / / / /
Herbal Medicine / / / / / TENS / / / /
Homeopathic medicine / / / / / Other – please state
...... / / / /
7. ABOUT YOUR PERIODS
Are you still having menstrual periods? No YesDate of first day of last period? DD YYY
Answer the following only if you are still having menstrual periods:
(please tick one box in each section)
In the last three months, have you had pelvic pain with your periods?
No /
Occasionally (with 1 in 3 of my periods) /
Often (with 2 in 3 of my periods) /
Always (every period) /
In the last three months, have you had pelvic pain at times other than with periods or sexual intercourse?
No /
Yes, just before a period /
Yes, just after a period /
How regular are your periods?
Regular, I know when to expect my period /
Fairly regular, my period starts within a few days of when I expect /
Irregular, I cannot predict when my period will start /
I have bleeding on and off all the time /
My periods are: Light Moderate Heavy Bleed through protection
How many days of bleeding do you usually have each period?
(We mean bleeding for which you need a tampon or sanitary
pad, NOT discharge for which you needed a panty liner only) ______days
How many days between the start of one period and the start of next, on average? ______days
Do you pass clots in menstrual flow? No Yes
Does pain start the day flow starts? No Yes Pain starts ______days before flow
8. PREVIOUS DIAGNOSIS
Has a doctor ever given you a diagnosis of any of the following? (please indicate with a tick)
No / Yes / No / YesEndometriosis / / / Uterine or bladder prolapse / /
Adhesions / / / Vulva pain/Vulvodynia / /
Fibroids / / / Irritable bowel syndrome / /
Adenomyosis / / / Nerve entrapment in pelvis/pudendal neuropathy / /
Uterine Polyps / / / Fibromyalgia / /
Ovarian cysts / / / Painful bladder syndrome (interstitial cystitis) / /
Appendicitis / / / Sexually transmitted infection / /
Hernia / / / Female circumcision/cutting / /
Infertility or low fertility / /
9. PREVIOUS TESTS
Have you ever had a cervical screening (smear) test? / No / Yes / If yes, when was your last test (roughly)?If yes, what the outcome? / Normal / Abnormal changes
Have you ever had a Chlamydia test? / No / Yes / If yes, when was your last test (roughly)?
If yes, what the outcome?
No Chlamydia / Treated for Chlamydia / Chlamydia but was not treated
10. PREVIOUS INVESTIGATIONS/OPERATIONS
Which of the following previous investigations have you had for pelvic pain? (please indicate with a tick)
No / Yes / No / YesLaparoscopy (telescope examination through belly) / / / Laparotomy (open surgery) / /
Cystoscopy (telescope examination of the bladder) / / / Ultrasound via vagina / /
Colonoscopy (telescope examination of the bowel) / / / Ultrasound on abdomen / /
Hysteroscopy (telescope examination via the vagina) / / / Nerve transmission test / /
Magnetic resonance (MRI) scan / / / Allergy tests
Other – please state......
11. ABOUT CONTRACEPTION
Are you sexually active? No Yes If yes, please answer the question about contraceptionAre you trying for a baby? No Yes If yes, please go to section 14
If you are using contraception, please tick all the methods of contraception you use:
No / Yes / No / Yes
Patch / /
Female sterilisation (clips) / / / Implant / /
Female sterilisation (implants) / / / Coil (Mirena) / /
Male partner sterilisation / / / Condom / /
Contraceptive pill / / / Diaphragm/cap / /
Mini-pill / / / Vaginal ring / /
Injection / / / Natural method / /
12. FERTILITY
Are you currently trying to get pregnant? / (please tick one box)No /
Yes, trying for less than a year /
Yes, trying for more than a year /
13. OTHER RECENT MEDICAL HISTORY
14. BOWEL SYMPTOMS
Do you ever experience rectal bleeding or blood in your stool during your period / Yes / NoDo you have problems with recurrent pain or discomfort in your abdomen? (please indicate/ tick)
More than 1 year / / More than 6 months /
Last month only / / No /
Considering the past 3 months, how often have you had pain or discomfort in the abdomen?
(please indicate/ tick)
All of the time / Most days of the month / At least 3 days per month / 1 day per month / Never
If you have had abdominal pain or discomfort, is this associated with any of the following
Improvement on going to the toilet to pass stool / Yes / No
A change in how often you go to the toilet / Yes / No
A change in the appearance (form) of the stool: / Yes / No
Rome Foundation Inc. Gastroenterology 2006;20(5):1377-90.
2
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry Version 2.1 - 27th November 2012
15. URINARY PROBLEMS
The following questions are about going to the toilet for a wee. This is also called voiding.
Some women sometimes feel a sudden, overwhelming need to go to the toilet. This is called urgency.
For each of the following questions, please circle the answer that best describes how you feel.
0 / 1 / 2 / 3 / 41 / How many times do you void (go for a wee) during waking hours? / 3-6 / 7-10 / 11-14 / 15-19 / 20+
2a / How many times do you void at night? / 0 / 1 / 2 / 3 / 4+
2b / If you get up at night, to what extent does it usually bother you? / Never / Mildly / Moderate / Severe
3 / Are you currently sexually active?
Yes No
4a / IF YOU ARE SEXUALLY ACTIVE, do you now, or have you ever had, pain or urgency to urinate during or after sexual intercourse? / Never / Occasionally / Usually / Always
4b / Has the pain or urgency ever made you avoid sexual intercourse? / Never / Occasionally / Usually / Always
5 / Do you have pain associated with your bladder or in your pelvis, vagina, lower abdomen, urethra (the opening from which you wee) or perineum (the area between your front and back passage)? / Never / Occasionally / Usually / Always
6 / Do you still have urgency shortly after urinating? / Never / Occasionally / Usually / Always
7a / When you have pain, is it usually? / Mild / Moderate / Severe
7b / How often does this pain bother you? / Never / Occasionally / Usually / Always
8a / When you have urgency, it is usually? / Mild / Moderate / Severe
8b / How often does this bother you? / Never / Occasionally / Usually / Always
Parsons C.L. J Reprod Med 2004;49(Supplement 3):235-42.