Confidential Persistent Pelvic Pain Form

Full Name (required)

Your Email (required)

Name of Diagnosis (required)

Referred by: (required)

Please describe your symptoms, including the precise area (required)

How and when did the problem start? How has it changed since it started (required)?

What is your biggest concern about the problem (required)?

What is your gut feeling about what is causing (or has caused) the problem, and what do you think is driving your pain (required)?

Have you had any past treatment for this condition? If yes, please describe (including whether it has changed your symptoms in any way) (required).

Please describe your menstrual cycle (include length of period, days between periods, heaviness of flow, any pain/discomfort, any pain relief used) (required)

What are your goals in coming to see me (required)?

Please list dates of any pregnancies or births, with as much detail as you can (required).

How many times per day do you go to the toilet to pass urine? (required)

Please describe any difficulties with passing urine (required).

How many times do you wake up overnight to go to the toilet to pass urine? (required)

How often do you pass a bowel motion? (required)

Do you have any bowel problems or concerns? Please describe (required).

Do you have any back pain, groin pain, hip pain or buttock pain? Please describe, including any previous treatment, and whether it helped (required)

Your occupation is: (required)

Please enter your height: (required)

Please outline any current exercise that you do (required)

Please list any previous surgery including approximate dates (required)

Please list any medical conditions or health concerns (required)

Is your weight stable, and are you comfortable with your fitness level (required)?