PELVIC PAIN QUESTIONNAIRE
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- Candace Fleming
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1 PELVIC PAIN QUESTIONNAIRE Name: DOB: / / Are you currently: Single Married Separated Divorced Re-married De-Facto Who do you live with? What type of employment are you currently in? How long? INFORMATION ABOUT YOUR PAIN Please describe your pain problem: What do you think is causing your pain? Is there an event that you associate with the onset of your pain? If so, what? How long have you had this pain? years months For each of the symptoms listed below, please rate your pain on a scale of 0 = no pain to 10 =worst imaginable (please circle) 1. Pain at ovulation (mid-cycle) Pain just before period Pain (not cramps) before period Deep pain with intercourse Pain in groin when lifting Pelvic pain last hours or days after intercourse Pain when bladder is full Muscle / Joint Pain Level of cramps with period Pain after period is over Burning vaginal pain after sex Pain with urination Backache Migraine Headache Pain with sitting What other physicians or health care providers have evaluated or treated you for chronic pelvic pain? Physician / Provider Name Speciality City, State, Phone (if known) 1
2 What types of practitioners or treatments have you tried in the past for your pain? (please tick) Acupuncture Herbal Medicine Osteopathy Anaesthesiologist Homeopathic Medicine Physiotherapy Anti-seizure medications Lupron, Synarel, Zoladex Psychotherapy Antidepressants Massage Psychiatry Botox Injections Meditation Rheumatologist Chiropractor Narcotics Skin Magnets Contraceptive pills / patch / ring Naturopathic medication Surgery Danazol (Danocrine) Nerve blocks TENS Unit Gastroenterologist Neurosurgeon Trigger point injections General Practitioner Non-prescription medicine Urologist Gynaecologist Nutrition/diet Other: MENSTRUAL HISTORY: How old were you when you had your first menstrual period? Are you still having menstrual periods? Answer the following only if you are still having menstrual periods Periods are: Light Moderate Heavy Bleed through protection Date of first day of your last menstrual period: / / How many days between your periods? days Do you have the following symptoms? (Please circle one) 1. Are your periods regular? 2. Pain with periods? 3. Does pain start the day flow starts? Pain starts days before the flow 4. Do you pass clots in menstrual flow? 5. Do you have spotting in between periods? 6. Have you had bleeding after sex? Birth control method: Nothing Pill IUD Vaginal Ring Depo Provera Diaphragm Condom Hysterectomy Vasectomy Tubal Sterilisation Other MEDICAL HISTORY Please list any medical problems/diagnoses Allergies (Including food, latex etc) Who is primary care provider? Have you ever been hospitalised for anything besides childbirth? If YES, please explain Have you had any major accidents such as falls or a back injury? Have you ever been treated for depression or anxiety? If YES, which treatment? Medication Hospitalisation Psychotherapy Other 2
3 PAIN MAPS Please shade areas of pain and write a number from 1 to 10 at the site(s) of pain (10 = worst imaginable) PREGNANCY HISTORY Total number of pregnancies including miscarriages, terminations, ectopic pregnancies and deliveries Year Place Gestation (Weeks) Type of Labour/Birth Birth Weight Gender Breast Fed Y/N Name Were there any complications during pregnancy, labour, delivery or post-partum? Episiotomy, degree Caesarean Section Vacuum Extraction Forceps Vaginal laceration Post-partum haemorrhage Medication for bleeding Other FAMILY HISTORY Has anyone in your family had? Fibromyalgia Chronic pelvic pain Irritable bowel syndrome Endometriosis Depression/Anxiety Interstitial cystitis Other chronic condition Cancer, what type? 3
4 List all Surgical Procedures you have had related to this pain: Year Procedure Surgeon Findings List all Surgical Procedures NOT related to this pain: Year Procedure Surgeon Findings MEDICATIONS Medication Dose Frequency Did it help? HEALTH HABITS How often do you exercise? Rarely 1-2 times per week 3-5 times per week Daily What is your caffeine intake? (Number cups per day including coffee, tea, soft drinks) cups Do you smoke cigarettes? / Ex-smoker If YES, how many a day? How many years? Do you drink alcohol? If YES, how many drinks per week? Have you ever received treatment for substance abuse? What is your use of recreational drugs? Never used Used in past Currently using If used in past or currently using, which? Heroin Cocaine Marijuana Barbiturates Amphetamines Other EATING How would you describe your diet? (tick all that apply) Well balanced Vegan Vegetarian Fatty or fried foods Special diet Other Do you have nausea? No With pain Taking Medications With eating Other Do you have vomiting? No With pain Taking Medications With eating Other Have you ever had an eating disorder such as anorexia or bulimia? 4
5 GASTROINTESTINAL Are you experiencing rectal bleeding or blood in your stool? Do you have increased bowel movements? The following questions help to diagnose irritable bowel syndrome, a gastrointestinal condition, which may be a cause of pelvic pain. Do you have pain or discomfort that is associated with the following? 1. Change in frequency of bowel movement 2. Change in appearance of stool or bowel movement 3. Does your pain improve after a bowel movement URINARY SYMPTOMS Do you experience any of the following? 1. Loss of urine when coughing, sneezing or laughing 2. Difficulty passing urine 3. Frequent bladder infections 4. Blood in urine 5. Still feeling full after urination 6. Having to void again within minutes of voiding The following questions help to diagnose painful bladder syndrome, which may cause pelvic pain. Please circle the answer that best describes your bladder function and symptoms How many times do you go to the bathroom during the DAY? How many times do you go to the bathroom at NIGHT? If you get up at night to void and empty your bladder does it bother you? Never Mildly Moderately Severely Are you currently sexually active? If you are sexually active, do you now or have Never Occasionally Usually Always you ever had pain or symptoms during or after sexual intercourse? If you have pain associated with intercourse, Never Occasionally Usually Always does it make you avoid sexual intercourse? Do you have pain associated with bladder or in Never Occasionally Usually Always your pelvis (lower abdomen, labia, vagina, urethra, perineum)? Do you have urgency after voiding? Never Occasionally Usually Always If you have pain, is it usually? Mild Moderate Severe Does your pain bother you? Never Occasionally Usually Always If you have urgency, is it usually Mild Moderate Severe Does your urgency bother you? Never Occasionally Usually Always 5
6 PAIN & PAIN MANAGEMENT Who are the people you talk to concerning your pain, or during stressful time? Spouse/Partner Relative Support Group Clergy Friend Doctor/Nurse Mental Health Provider I take care of myself Other How does your partner deal with your pain? Not applicable Doesn t notice when I m in pain Takes care of me Withdraws Feels helpless Distracts me with activities Gets angry What helps your pain? Meditation Relaxation Lying down Music Massage Ice Heat pad/bag Hot Bath Pain Medication Laxatives/Enema Injection TENS unit Bowel Movement Emptying Bladder Nothing Other What makes your pain worse? Intercourse Orgasm Stress Full meal Bowel movement Full bladder Urination Standing Walking Exercise Time of day Weather Contact with clothing Coughing/sneezing Not related to anything Other Of all the problems or stresses in your life, how does your pain compare in importance? The most important Just one of many problems Is your pelvic pain aggravated by prolonged physical activity? Does your pelvic pain improve when you lie down? Do you have pain that is deep in the vagina or pelvis during sex? Do you have pelvic throbbing or aching after sex? Dr you have pelvic pain that moves from side to side? Do you have sudden episodes of severe pelvic pain that come and go? Have you ever been a victim of emotional, physical or sexual abuse? / Unsure If YES, which type? Were you at the time a, CHILD / ADULT / BOTH If YES, how long for? Have you had counselling or treatment? The words below describe pain. Please tick the column which best represents the degree to which you feel the pelvic pain. Type None = 0 Mild = 1 Moderate = 2 Severe = 3 Throbbing Shooting Stabbing Sharp Cramping Gnawing Hot-Burning Aching Heavy Tender Splitting Tiring Exhausting Fearful Punishing - Cruel Sickening 6
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PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:
Patient Name: Patient Date of Birth: Appointment Date: Please mark and/or notate the areas of your body which are affected by pain. RIGHT RIGHT LEFT LEFT RIGHT LEFT RIGHT RIGHT LEFT LEFT RIGHT LEFT For
Name MR# Date Name of your primary care physician: Name of your OB/GYN physician:
Women s Specialty Care, Urogynecology Division Husam Abed, MD, and Paul Moore, MD Locations Mirror Lake 2925 Layfair Drive, Flowood, MS 39232 Jackson Medical Mall 350 Woodrow Wilson Drive, Jackson, MS
Patient Intake Form for Acupuncture Treatment at Infinite Healing
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Lucas D. Brown, L.Ac. (312)
Today s date: Mr. Miss Mrs. Ms. Dr. Birth date: (mm/dd/yy) Social Security Number: First name: Last name: Age: Email: Marital status: Single Divorced Married Separated Partner Widowed Street address: Apt:
Medical History Form M Clear Passage Physical Therapy
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Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
GUPTA SPORTS & SPINE CENTER
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Urogyn Initial Visit Packet
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SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell