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.

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* 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.

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* 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.

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* 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.

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* 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)

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* 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.

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* 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)

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* 7. How long have you been living with this pain?

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* 8. Has your pain become worse over time?

Yes

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* 9. What medications (pharmaceutical, herbal, nutritional) do you currently use to manage your pain?

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* 10. What treatments (eg. meditation, massage, exercise, hot water bottle etc) do you use to help manage your pain?

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* 11. Does your pain affect your work or school?

Yes

More info?

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* 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

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* 13. If you answered 'Yes' to Q12 please enter your contact details here

Name

Email Address

Phone Number

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* 14. Anything else you'd like to tell us?

For further information about Endometriosis (signs, symptoms, fact sheet, journal, treatment etc) click here >>>