Endometriosis Symptom Questionnaire Do you suspect you may have endometriosis? These are the types of questions your GP will ask you whilst investigating your endometriosis prognosis. If you would like us to contact you to organise an appointment to review your symptoms, leave us your preferred contact details (name, phone and/or email) at question 10 and we will be in touch asap. OK Question Title * 1. During your menstrual period, do you usually experience pain in your pelvic region, lower back, abdomen and/or stomach? No Pain Moderate Pain Debilitating Pain Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 2. When you are NOT menstruating, do you experience pain in your pelvic region, lower back, abdomen or stomach? Never Sometimes Regularly Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 3. Do you experience pain during sex? No pain Moderate pain Excruciating pain Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 4. Have you experienced any of the following symptoms (check all that apply) Bleeding or spotting between periods Heavy bleeding during your period Painful bowel movements Painful urination Bloating Fatigue Feeling unwell, faint or nauseous during your period Other (please specify) OK Question Title * 5. Do you experience debilitating pain, exhaustion and/or weakness, which disables you from actively participating in life activities Never Sometimes Very Regularly Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 6. Have you been diagnosed with any of the following? (tick all that apply) Irritable Bowel Syndrome (IBS) Infertility (difficulty with falling pregnant) Uterine Fibroids (UF) Interstitial Cystitis (Painful bladder syndrome) Other (please specify) OK Question Title * 7. How long have you been living with this pain? OK Question Title * 8. Has your pain become worse over time? Yes No OK Question Title * 9. What medications (pharmaceutical, herbal, nutritional) do you currently use to manage your pain? OK Question Title * 10. What treatments (eg. meditation, massage, exercise, hot water bottle etc) do you use to help manage your pain? OK Question Title * 11. Does your pain affect your work or school? Yes No More info? OK Question Title * 12. Would you like us to organise an initial tele-health appointment to review your diagnostic? If yes, please include your preferred contact details below. Include your name, email and/or phone number. Yes No OK Question Title * 13. If you answered 'Yes' to Q12 please enter your contact details here Name Email Address Phone Number OK Question Title * 14. Anything else you'd like to tell us? OK For further information about Endometriosis (signs, symptoms, fact sheet, journal, treatment etc) click here >>> OK DONE.