Skip to content

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.
1.During your menstrual period, do you usually experience pain in your pelvic region, lower back, abdomen and/or stomach?(Required.)
No Pain
Moderate Pain
Debilitating Pain
2.When you are NOT menstruating, do you experience pain in your pelvic region, lower back, abdomen or stomach?
Never
Sometimes
Regularly
3.Do you experience pain during sex?
No pain
Moderate pain
Excruciating pain
4.Have you experienced any of the following symptoms (check all that apply)
5.Do you experience debilitating pain, exhaustion and/or weakness, which disables you from actively participating in life activities
Never
Sometimes
Very Regularly
6.Have you been diagnosed with any of the following? (tick all that apply)
7.How long have you been living with this pain?
8.Has your pain become worse over time?
9.What medications (pharmaceutical, herbal, nutritional) do you currently use to manage your pain?
10.What treatments (eg. meditation, massage, exercise, hot water bottle etc) do you use to help manage your pain?
11.Does your pain affect your work or school?
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.
13.If you answered 'Yes' to Q12 please enter your contact details here
14.Anything else you'd like to tell us?
For further information about Endometriosis (signs, symptoms, fact sheet, journal, treatment etc) click here >>>
Current Progress,
0 of 14 answered
Privacy & Cookie Notice