Pelvic Pain Clinic Screening Form

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Personal Details

First Name *

Last Name *

Email Address *

Date of Birth *

Pronouns *

She/herThey/themHe/himShe/theyHe/theyOther

Do you consider yourself to be transgender?

YesNo

What is your sexual orientation?

Heterosexual (straight)Gay/lesbianBisexual Asexual Other

Do you identify as Aboriginal and/or Torres Strait Islander? *

YesNo

Do you come from a Culturally and Linguistically Diverse (CALD) background? *

YesNo

Do you have private health insurance? *

YesNoUnsure

How did you end up here with us today? *

Self-referralSpecialist referral Other

Please select the symptoms you are currently experiencing *

Pelvic pain Back pain Bowel symptomsBladder symptomsSleep symptoms Mental health Heavy periodsNil/other

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Pelvic Pain Symptoms

How many days each month do you have pelvic pain or discomfort of any kind? *123456789101112131415161718192021222324252627282930

How many days each month are you entirely well with no pelvic discomfort at all? *123456789101112131415161718192021222324252627282930

How many times in the past 6 months have you seen a GP regarding your pain? *01-23-45+

How many times in the past 6 months have you seen a medical specialist regarding your pain? *01-23-45+

How many times in the past 6 momnths have you seen a health practitioner, other than a doctor (e.g., psychologist, physiotherapist, complementary therapist) regarding your pain? *01-23-45+

How many times in the past 6 months have you visited a hospital emergency department regarding your pain? *01-23-45+

How many times in the past 6 months have you been admitted to a hospital regarding your pain? *01-23-45+

How many times in the last 6 months did you miss work or school due to your pain? *01-1011-2021-3031-4041-5051-6060+

How many times in the last 6 months was your productivity at work or school reduced by half or more because of your pain? *01-1011-2021-3031-4041-5051-6060+

How many times in the last 6 months were you unable to do household work because of your pain? *01-1011-2021-3031-4041-5051-6060+

How many diagnostic tests (e.g. ultrasounds, CT scans) have you had in the past 6 months regarding your pain? *01-56-1011-1516-2020+

Do you have vulval pain? *

YesNo

Please rate your vulval pain between 0 and 10, where 0 is no pain at all and 10 is the worst possible pain *012345678910

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Back Pain

Do you have back pain *

YesNo

Please rate your back pain between 0 and 10, where 0 is no pain at all and 10 is the worst possible pain *012345678910

Please select the most relevant answer that applies to you and your back pain *

YesNoOccasionally

I can look after myself normally without extra pain

YesNoOccasionally

I can look after myself but it causes extra pain

YesNoOccasionally

It's painful to look after myself

YesNoOccasionally

I require help to look after myself due to my pain

YesNoOccasionally

I can lift heavy objects without extra pain

YesNoOccasionally

I can lift heavy objects but it gives extra pain

YesNoOccasionally

I can only lift light objects

YesNoOccasionally

I cannot lift anything due to pain

YesNoOccasionally

I can run or walk without pain

YesNoOccasionally

I can walk comfortably but running is painful

YesNoOccasionally

Pain prevents me from being physically active

YesNoOccasionally

I can sit in any chair as long as I want

YesNoOccasionally

Pain prevents me from sitting for more than one hour

YesNoOccasionally

Pain prevents me from sitting at all

YesNoOccasionally

I can stand as long as I want

YesNoOccasionally

Pain prevents me from standing for more than one hour

YesNoOccasionally

Pain prevents me from standing at all

YesNoOccasionally

I sleep well

YesNoOccasionally

Pain interrupts my sleep

YesNoOccasionally

I never sleep well due to my pain

YesNoOccasionally

Pain has restricted my social life

YesNoOccasionally

My pain does not affect my social life

YesNoOccasionally

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Bowel Symptoms

Please select the option that best describes your bowel symptoms *

YesNoSometimesOccasionally

Do you have problems with your bowel?

YesNoSometimesOccasionally

Do you have constipation?

YesNoSometimesOccasionally

Do you have diarrhoea?

YesNoSometimesOccasionally

Do you feel bloated?

YesNoSometimesOccasionally

Do you have bowel pain?

YesNoSometimesOccasionally

Do you have blood in your stool?

YesNoSometimesOccasionally

Do you have pain associated with your bowels?

YesNoSometimesOccasionally

Do you have urgency associated with the need to open your bowels?

YesNoSometimesOccasionally

Are there foods that don't suit you?

YesNoSometimesOccasionally

On average, how many times do you experience bowel movements during the day? *012345678910+

On average, how many times do you experience bowel movements at night? *012345678910+

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Bladder Symptoms

Please select the option that best describes your bladder symptoms *

YesNo SometimesOccasionally

Do you have problems with your bladder?

YesNo SometimesOccasionally

Are there times when you find it difficult to pass urine during the night?

YesNo SometimesOccasionally

Are there times where you have to rush to the toilet to urinate?

YesNo SometimesOccasionally

Does urine leak before you can get to the toilet?

YesNo SometimesOccasionally

Do you have pain with urination?

YesNo SometimesOccasionally

How many times do you pass urine each day while awake? *012345678910+

How many times do you pass urine during the night? *012345678910+

How much fluid do you drink each day? *Less than 1L1L2L3L4L5L+

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Headache Symptoms

Do you get headaches? *

YesNo

How many headaches do you get each month? *

0-23-56-89-1010+

How long do your headaches last? *

Less than 30 minutes30 minutes -1 hour1-2 hours2-4 hours5-10 hours10 hours +

How would you describe the pain of your headaches? *

ThrobbingPulsatingDullAchingPressure-likeSharpStabbingMigraine Headaches

Please rate your headache pain on a scale of 1-10 *12345678910

Do you have face and scalp sensitivity with your headaches? *

YesNoUnsure

Are your headaches worse at period time? *

YesNoUnsure

Do you have any of the following symptoms associated with your headaches? *

Neck pain NauseaVomitingLight sensitivityNoise sensitvityDizzinessNumbnessWeaknessFeverConfusionDifficulty SpeakingNasal CongestionEyelid DroopingNone of the Above

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Past Medical History

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

Please list any previous medical diagnoses you have had, and they year they were made *

Please list any medications that you are currently taking *

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Menstrual History

How old were you when your periods started? *

Do you have period pain? *YesNoOccasionallySometimesOften

Please rate your period pain between 0 and 10, where 0 is no pain and 10 is the worst possible pain *012345678910

How many days per month do you have pain now? *123456789101112131415161718192021222324252627282930

Do you have sudden or stabbing pains in the pelvic region? *YesNoOccasionallySometimesOften

Please rate this sudden/stabbing pain between 0 and 10, where 0 is no pain and 10 is the worst possible pain *012345678910

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Sexual and Reproductive Health

Please select the option that best applies to you *

YesNoUnsure

Have you ever been pregnant?

YesNoUnsure

Are you trying to become pregnant?

YesNoUnsure

Is fertility something that concerns you?

YesNoUnsure

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

YesNoUnsure

Do you feel pain or discomfort during sexual activity? *

YesNoOccasionally SometimesAlways

When do you get this pain? *

During after intercourseImmediately after intercourseThe day after intercourseWith arousal

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

YesNoI would like to discuss this during my appointmentI would not like to discuss this during my appointment

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Medical Conditions

Have you ever been diagnosed with any of these conditions? *

YesNo

Endometriosis (found by laparoscopy)

YesNo

Endometriosis (found by ultrasound scan)

YesNo

Suspected Endometriosis (clinical diagnosis)

YesNo

Arthritis, thyroid disease, Coeliac disease

YesNo

Ulcerative Colitis or Crohns Disease

YesNo

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

YesNo

Migraine Headaches

YesNo

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

YesNo

Headaches

YesNo

Abdominal Pain

YesNo

Bowel Problems

YesNo

Bladder Problems

YesNo

Arthritis

YesNo

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

EndometriosisMigraine HeadachesLong-term Pain ConditionArthritis, Thyroid Disease, SLE, Coeliac DiseaseUlcerative Colitis or Crohns DiseaseNone of the aboveUnsure

Are there any other medical conditions in the family we should know about? *

Body Pain Map *

Clear drawing

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

Vulval Pain *

Clear drawing

If you have vulval or vaginal pain, please indicate in every square where you have felt pain in the past 3 months

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DASS 21

The DASS 21 Questionnaire is a measure of mental health and psychological wellbeing, and helps us to better understand how your pelvic pain is impacting you psychologically. 

Please read each statement and select an option which 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. 

I found it hard to wind down *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I was aware of dryness in my mouth *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I couldn't seem to experience any positive feeling at all *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness in the absence of physical exertion) *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I found it difficult to work up the initiative to do things *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I tended to over-react to situations *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I experienced trembling (e.g., in the hands) *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I felt that I was using a lot of nervous energy *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I was worried about situations in which I might panic and make a fool of myself *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I felt that I had nothing to look forward to *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I found myself getting agitated *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I found it difficult to relax *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I felt down-hearted and blue *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I was intolerant of anything that kept me from getting on with what I was doing *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I felt I was close to panic *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I was unable to become enthusiastic about anything *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I felt I wasn't worth much as a person *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I felt I was rather touchy *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I was aware of the action of my heartbeat in the absence of physical exertion (e.g., sense of heart rate increase, heart missing a beat) *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I felt scared without any good reason *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

I felt that life was meaningless *

Never: Did not apply to me at allSometimes: Applied to me to some degree, or some of the timeOften: Applied to me to a considerable degree, or a good part of the timeAlmost Always: Applied to me very much, or most of the time

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Depression Score0-4 = Normal; 5-6 = Mild; 7-10 = Moderate; 11-13 = Severe; 14+ = Extremely Severe

Anxiety Score0-3 = Normal; 4-5 = Mild; 6-7 = Moderate; 8-9 = Severe; 10+ = Extremely Severe

Stress Score0-7 = Normal; 8-9 = Mild; 10-12 = Moderate; 13-16 = Severe; 17+ = Extremely Severe

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Insomnia Sleep Index

The Insomnia Severity Index has seven questions. 

For each question, please select the option that bestdescribes your answer. 

Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).

Difficulty falling asleep *

NoneMild ModerateSevereVery Severe

Difficulty staying awake *

NoneMild ModerateSevereVery Severe

Problems waking up too early *

NoneMildModerateSevereVery Severe

How satisfied/dissatisfied are you with your current sleep pattern? *

Very satisfiedSatisfiedModerately satisfiedDissatisfiedVery dissatisfied

How noticeable to others do you think your sleep problem is in terms of impairing the quality of your life? *

Not noticeableA littleSomewhatMuchVery much noticeable

How worried/distressed are you about your current sleep situation?

Not worriedA littleSomewhatMuchVery much worried

To what extent do you consider your sleep problem to currently interfere with your daily functioning? (E.g., daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, etc.)

Not interferingA littleSomewhatMuchVery much interfering

Insomnia Sleep Index Score0-7 = No clinically significant insomnia; 8-14 = Subthreshold insomnia; 15-21 = Clinical insomnia (moderate severity); 22-28 = Clinical insomnia (severe)

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Central Sensitisation Inventory

The Central Sensitization Inventory (CSI) may be used to determine severity of central sensitisation, which indicates how sensitive your body is to pain and how your body reacts to painful stimuli. 

Of the following 25 questions, please select the option that is most relevant to you. 

I feel tired and unrefreshed when I wake from sleeping *

Never RarelySometimesOftenAlways

My muscles feel stiff and achy *

Never RarelySometimesOftenAlways

I have anxiety attacks *

Never RarelySometimesOftenAlways

I grind or clench my teeth *

Never RarelySometimesOftenAlways

I have problems with diarrhoea and/or constipation *

Never RarelySometimesOftenAlways

I need help in performing my daily activities *

Never RarelySometimesOftenAlways

I am sensitive to bright lights *

Never RarelySometimesOftenAlways

I get tired very easily when I am physically active *

Never RarelySometimesOftenAlways

I feel pain all over my body *

Never RarelySometimesOftenAlways

I have headaches *

Never RarelySometimesOftenAlways

I feel discomfort in my bladder and/or burning when I urinate *

Never RarelySometimesOftenAlways

I do not sleep well *

Never RarelySometimesOftenAlways

I have difficulty concentrating *

Never RarelySometimesOftenAlways

I have skin problems such as dryness, itchiness, or rashes *

Never RarelySometimesOftenAlways

Stress makes my physical symptoms get worse *

Never RarelySometimesOftenAlways

I feel sad or depressed *

Never RarelySometimesOftenAlways

I have low energy *

Never RarelySometimesOftenAlways

I have muscle tension in my neck and shoulders *

Never RarelySometimesOftenAlways

I have pain in my jaw *

Never RarelySometimesOftenAlways

Certain smells, such as perfumes, make my feel dizzy and nauseated *

Never RarelySometimesOftenAlways

I have to urinate frequently *

Never RarelySometimesOftenAlways

My leg feel uncomfortable and restless when I am trying to go to sleep at night *

Never RarelySometimesOftenAlways

I have difficulty remembering things *

Never RarelySometimesOftenAlways

I suffered trauma as a child *

Never RarelySometimesOftenAlways

I have pain in my pelvic area *

Never RarelySometimesOftenAlways

Central Sensitisation Score0-29 = Subclinical; 30-39 = Mild; 40-49 = Moderate; Severe = 50-59; Severe = 60+

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Have you been diagnosed with and of the following conditions by a medical doctor? *

Yes No

Restless Leg Syndrome

Yes No

Chronic Fatigue Syndrome

Yes No

Fibromyalgia

Yes No

Temporomandibular Joint Disorder (TMJ)

Yes No

Migraine or Tension Headaches

Yes No

Irritable Bowel Syndrome

Yes No

Multiple Chemical Sensitivities

Yes No

Neck Injury (including Whiplash)

Yes No

Anxiety or Panic Attacks

Yes No

Depression

Yes No

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Pain Catastrophising Scale

Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures, surgery, and ongoing pelvic pain.

We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain, which can be used to indicate the degree to which you have these thoughts and feelings when you are experiencing pain.

Please select the option that best completes the statement "when I'm in pain..." for you. 

I worry all the time about whether the pain will end *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

I feel I can't go on *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

It's terrible and I think it's never going to get any better *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

It's awful and I feel that it overwhelms me *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

I feel I can't stand it anymore *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

I become afraid that the pain will get worse *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

I keep thinking of other painful events *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

I anxiously want the pain to go away *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

I can't seem to keep it out of my mind *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

I keep thinking about how much it hurts *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

I keep thinking about how badly I want the pain to stop *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

There's nothing I can do to reduce the intensity of the pain *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

I wonder whether something serious may happen *

Not at all To a slight degreeTo a moderate degreeTo a great degreeAll the time

Pain Catastrophising Scale ScoreA total score of >30 represents a clinically significant level of pain catastrophization.

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5 Point Hypermobility Questionnaire

Can you now (or could you ever) place your hands flat on the floor without bending your knees? *

YesNo

Can you now (or could you ever) bend your thumb to touch your forearm? *

YesNo

As a child, did you amuse your friends by contouring your body into strange shapes, OR could you do the splits? *

YesNo

As a child or teenager, did your shoulder or kneecap dislocate on more than one occasion? *

YesNo

Do you consider yourself double-jointed? *

YesNo

Hypermobility Questionnaire ResultA score of 2 or more suggests generalised joint hypermobility

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Pelvic Congestion Syndrome Screen

Do you suffer from pain in the legs on being in the standing or sitting position for a while? *

YesNo

Do you suffer from leg swelling on being in the standing or sitting position for a while? *

YesNo

Do you suffer from pain at the buttock and/ or perineal (undercarriage or private areas) region on being in the standing or sitting position for a while? *

YesNo

Do you suffer from regular coital (related to sexual intercourse) pain? *

YesNo

Do you suffer pain during micturition (passing urine) or an urgency to pass urine on a regular basis? *

YesNo

Is the severity of your pain or discomfort get worse closer to your menstrual period? *

YesNo

Basic PCS Score *If your Basic PCS score is 2 or more; or if you have pelvic pain or discomfort for 6 months or more with any of the symptoms above – move on to questions in the PCS Specific score section

Do you have varicose veins in the groin or in and around your private areas and vagina now; or have had them during or after pregnancy in the past? *

YesNo

Do you suffer from regular post coital (after sexual intercourse) pain or an ache deep within the private areas and pelvis after sex? *

YesNo

Have you had gynaecological procedures like laparoscopies, hormone treatments and implants or referrals to chronic pain management for a diagnosis of endometriosis over many years but have had no relief from the pain? *

YesNo

Have you had a CT scan or MRI scan that has shown dilated (enlarged) veins in your pelvis? *

YesNo

Total PCS ScoreTotal PCS Score 0,1 or 2 – The chances that you have PCS (a Pelvic Venous Disorder) is very low. Total PCS Score 3 to 6 – There is a real possibility that your symptoms may be due to PCS (a Pelvic Venous Disorder). Total PCS Score 7-14 – There is a very high chance that you are suffering from PCS (a Pelvic Venous Disorder).

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Conclusion

What services are you hoping to access at the Pelvic Pain Clinic? *

Pelvic Physiotherapy PsychologyGP Appointment Dietician Referral to specialsitsOther

What are the main goals that you are hoping to achieve through the pelvic pain clinic? (Choose as many as you feel are relevant). *

Improve daily functioningEnhance quality of lifeDevelop self-management strategiesAchieve effective pain managementTreatment of heavy/painful periodsReferral to a gynaecologistEstablish a support networkImprove sleep qualityEnhance emotional wellbeingReduce bowel and gut symptomsManage painful sexSupport regarding fertilityDeveloping a safe exercise programGuidance on diet to improve symptomsReferral to a pain specialistReferral for further investigations such as specialised ultrasound Other

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Do you give permission to anonymously use this data for clinical research? (All data is de-identified, permission can be withdrawn at any time). *

YesNo

Do you consent for us to send you email updates on resources, links, useful information and services? *

YesNo

Do you consent for providers at the pelvic pain clinic (for example your GP, clinic nurse, physiotherapist, dietician, psychologist, gynaecologist) to discuss your progress and treatment plan within a multidisciplinary team meeting? *

YesNo

Today's Date *

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Thank you for completing this form. It helps us to understand what symptoms you are experiencing and how we can best help you through your journey with pelvic pain. Upon submission of this form please phone The Garden Family Medical Clinic on (08) 6186 7992 to book your screening appointment with our Pelvic Pain Nurse. 

Please note: A $100 non-refundable deposit is required at the time of booking your telephone screening appointment, which will be taken off the cost of the initial GP appointment once you attend. For Health Care Card holders who are eligible for a bulk-billed appointment, this deposit will get refunded back to you after the completion of your GP Appointment.

This is to maximise the longevity of the service that we provide and ensures continuity of care, appropriate diagnosis and management planning by our General Practitioners, and proper engagement with the full Pelvic Pain Clinic multidisciplinary care model. This leads to the best possible outcomes for our patients.

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