Intake Questionnaires

Thank you for completing these intake questionnaires for the Endometriosis and Pelvic Pain (EPP) program at the Coffs Harbour Women's Health Centre.

This is a collection of questionnaires (3 in total), that together give us an idea of the pain you experience, as well as other related symptoms. If you are unsure of how to answer a question, make a note in any of the "Notes" sections and these can be discussed during your first appointment.

Information will remain confidential and will only be viewed by relevant members of the EPP Clinic team.

Content warning: some questions pertain to traumatic experiences. Answering these is optional.

At any stage, you can scroll to the bottom and save your answers to come back to later.

Our EPP team of health professionals are committed to helping those with pelvic pain by providing information, resources, education and focused health care within a multi-disciplinary team, of women’s health (WH) GPs, nurses, physiotherapists, dietitians and pelvic pain educator.

Eligibility Criteria

This clinic is for females and those assigned female at birth who are of reproductive age with any of the following:

suspected or confirmed endometriosis
significant pain with periods
concerning menstrual cycle symptoms

Timeframe

You can access support through the program for up to 12 months from your start date. As this is a specialised service with limited availability, we encourage you to make the most of the support offered during this time. Please note, you can only access this program once.

Attendance

We encourage you to attend all scheduled appointments. If you miss two appointments without notice, you will be discharged from the clinic to allow access for others.

*Please note, we cannot provide prescriptions for S8 medication (e.g. codeine, endone) through our service. We also cannot offer surgical or gynaecology services (but we can provide referrals and recommendations).

* We can also only provide services to people within our primary healthcare network of Northern NSW. For more information and to see if your region is eligible, please see https://hnc.org.au/our-region/

If you want to know more about the EPP Clinic or our centre, please call us on (02) 6652 8111, or email whc@healthvoyage.org.au

First name *

Last name *

Preferred name

Phone number *

Date of Birth *

Email address *

Street address *

Suburb/Town *

State *

Postcode *

Suburb

Today's date *

To comply with privacy laws, your agreement to the following is required:

I agree to allow Coffs Harbour Women's Health to store my personal and health information as disclosed in this form, for the purposes of health care provision. *

Please refer to our policy/privacy statement for more information generally on the management of personal information (including health information) by this practice. This is available at: https://healthvoyage.org.au/coffs-harbour-womens-health-centre/patient-information/

Your permission to use this data for research

It is possible that we may wish to use the information in this questionnaire anonymously in the future for research purposes. We will only do this with your consent. Please note that any of your personal details would be removed from this record before it was used for research and you would not be identified in any way. Whether you select yes or no, it will not affect the way we care for you, or your relationship with us.

Please select one option *

Yes, I agree to this information being used anonymously for researchNo, I do not agree to this information being used anonymously for research

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Can you tell us what kind of health professional?

Are you of Aboriginal and/or Torres Strait Islander origin? *

Yes, I am of Aboriginal and/or Torres Strait Islander originNoPrefer not to answer

Do you identify as coming from a culturally and/or linguistically diverse background? *

Yes*NoPrefer not to answer

*This may include people who: were born outside Australia; speak a language other than English; belong to a culturally diverse, migrant or ethnic community; or identify with a cultural background different from the mainstream Australian population.

Do you self-identify as LGBTQIA+? *

Yes - I identify as any of the following: lesbian, gay, bisexual, transgender, queer, intersex, asexual and/or aromantic, or as another identity that doesn't quite fit these other labelsNoPrefer not to answer

Do you self-identify as having a disability? *

YesNoPrefer not to answer

Please specify

Questionnaire 1

Pelvic Pain Foundation of Australia Pain Questionnaire

Period pain, pelvic pain and endometriosis are complex conditions. By answering these questions you will help us understand your concerns better and allow us more time at your visit to discuss the issues that are most important to you.

For some questions we have asked you to tell us how bad your pain is on a scale from 0-10. A score of 0 would mean no pain at all, and 10 would be the worst pain you can imagine. Other questions ask you to select the answer that describes your pain best. If your problems aren’t the same each month, think about how they have affected you over the last 3 months.

Firstly, what is the problem that bothers you the most?

Your pain and how your pain affects your life

1. Your age

2. How many days each month do you have pelvic pain or discomfort of any kind?

3. How many days each month are you entirely well with no pelvic discomfort at all?(Please note that the answers to Question 2 and Question 3 should add up to 30)

4. How many times in the past 3 months have you seen a GP regarding your pain?

5. How many times in the past 3 months have you seen a medical specialist regarding your pain?

6. How many times in the past 3 months have you seen a health practitioner, other than a doctor (e.g. psychologist, physiotherapist, complementary therapist) regarding your pain?

7. How many times in the past 3 months have you visited a hospital emergency department regarding your pain?

8. How many times in the past 3 months have you been admitted to hospital regarding your pain?

9. How many diagnostic tests (e.g. ultrasounds, CT scans) have you had in the past 3 months regarding your pain?

Your operations

10. Please list any operations you have had, the year they were done, and how long they helped your pain for, if at all

Operation

Year

This helped my pain for:

It did not help my pain

Your medications

11. Which medications or supplements do you take?

Medications I use with periods

Medications I use every day (including contraceptives)

Medications I use occasionally

Are you allergic to any medications? Which ones?

Your periods

12. How old were you when your periods started?

13. Do you have period pain?

YesNoOccasionally

Period pain score (0-10)

If so, how old were you when your periods became painful?

How many days each month do you have period pain now?

Do you have pelvic pain between periods too?

YesNo, I don’t have any pelvic pain between periods

If yes, how old were you when you started to have pelvic pain between periods too?

Do period pain medications (ibuprofen, Ponstan, Naprogesic etc) help your period pain?

Yes, a lotA little Not at allI have never tried these medications for period pain

Does the contraceptive pill help your period pain?

Yes, a lotA littleNot at allI have never tried the pill

Does an intrauterine device (IUD), such as a Mirena, help your period pain?

Yes, a lotA littleNot at allI have never tried an IUD

Does a rod implant (such as an Implanon) help your period pain?

Yes, a lotA littleNot at allI have never tried a rod implant

14. How heavily do you usually bleed with periods?

LightMediumHeavyVariable

15. Extra notes about your period, if relevant:

Stabbing pains in your abdomen, pelvis or back

16. Do you have sudden or stabbing pains in the pelvis?

YesNoOnly with periods

Pain score (0-10)

Do any exercises or movements make these pains worse?

YesNo

If yes, which exercises or movements make the pain worse?

Do any exercises or movements make these pains better?

YesNo

If yes, which exercises or movements help?

17. Do you have back pain?

YesNoOccasionallyOnly with periods

Back pain score (0-10)

Your bowel

18. Do you have problems with your bowel?

YesNoOccasionally

Do you have constipation?

YesNoSometimesOnly with periods

Do you have diarrhoea?

YesNoSometimesOnly with periods

Do you feel bloated?

YesNoSometimesOnly with periods

Do you have bowel pain?

YesNoOccasionallyOnly with periods

Are there foods that don’t suit you? If so, which ones?

Your bladder

19. Do you have problems with your bladder?

YesNoOccasionallyOnly with periods

How many times do you pass urine each day while awake?

How many times do you pass urine during the night?

Are there times when you find it difficult to start passing urine?

YesNoOccasionally

How much fluid do you drink each day?

Headaches

20. Do you get headaches?

YesNoOccasionallyOnly with periods

20a. Do you get headaches or migraines at period time?

YesNo

20b. Headaches Pain Score (0-10)

20c. How many days a month do you have a headache?

Your vulva

The vulva is the skin between your legs outside the vagina.

21. Do you have vulval pain?

YesNo

Vulval Pain Score (0-10)

Your general wellbeing

22. Do you have any of the following symptoms?

Unusual tiredness or fatigue

YesNoOnly with periods

Poor sleep

YesNoOnly with periods

Unusual sweating

YesNoOnly with periods

Dizziness or feeling faint

YesNoOnly with periods

Anxiety

YesNoOnly with periods

Low mood

YesNoOnly with periods

Nausea

YesNoOnly with periods

Difficulty thinking clearly

YesNoOnly with periods

Your sexual and fertility wellbeing

23. Have you ever been pregnant?

YesNo

Are you trying to become pregnant?

YesNo

24. Are you currently or have you ever been in a sexual relationship?

YesNoI prefer not to answer this question

If relevant:

Do you feel pain or discomfort during sexual activity?

YesNo

Sexual Pain Score (0-10)

When do you get this pain? (please select as many as apply)

With arousalDuring intercourseAfter intercourseThe day after intercourse

Have you experienced distressing sexual events during your life, including sexual assault?

YesNoI prefer not to answer this question

Select of the following:

I would like to discuss this during my appointmentI don't mind if we discuss this during my appointmentI would prefer not to discuss this during my appointment

Your medical conditions

25. Have you been diagnosed with any of these conditions?

Endometriosis (found by laparoscopy)

YesNo

Endometriosis (found by ultrasound scan)

YesNo

Adenomyosis

Yes - by ultrasoundYes - by surgeryNo

Arthritis, thyroid disease, or coeliac disease

YesNo

Ulcerative colitis or Crohns disease

YesNo

Clots in the legs or lungs, or a blood clotting condition

YesNo

Migraine headaches

YesNo

Other medical conditions we should know about? (Please list)

26. When you were a child, before starting your periods, did you have any medical conditions?

Headaches as a child

YesNo

Abdominal pain

YesNo

Bowel problems

YesNo

Bladder problems

YesNo

Arthritis

YesNo

Other childhood medical conditions

Your family history

27. Does anyone in your family have any of the following medical conditions?

Endometriosis

YesNo

If yes, who:

Notes

Your Body Pain Map

Please place a cross or scribble in every square where you have felt persistent or recurrent pain in the last 3 months.

Clear drawing

If you have vulval or vaginal pain, please place a cross in every square where you have felt persistent or recurrent pain in the last 3 months.

Clear drawing

DASS-21 (your mood)

Pain of any kind can be aggravated by stress, anxiety or depression. The last section of this questionnaire asks about your mood.

DASS21

Please read each statement and select which option indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

1. I found it hard to wind down *