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Pelvic Pain Assessment (301896-DT)

Pelvic Pain Assessment (301896-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Index to Questionnaire–Health\Encounter

UWH301896-DT (Rev. 02/10/17) PELVIC PAIN ASSESSMENT Page 1 of 3
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
PELVIC PAIN ASSESSMENT




Date: _________________________________
Information About Your Pain
Please describe your pain problem (use a separate sheet of paper if needed): _____________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
What do you think is causing your pain? __________________________________________________________________
Is there an event that you associate with the onset of your pain? □ Yes □ No If so, what? _________________________
How long have you had this pain? _____ years _____ months

For each of the symptoms listed below, please “bubble in” your level of pain over the last month using a 10-point scale:
0 – no pain 10 – the worst pain imaginable

How would you rate your pain? 0 1 2 3 4 5 6 7 8 9 10
Pain at ovulation (mid-cycle) O O O O O O O O O O O
Pain just before period O O O O O O O O O O O
Pain (not cramps) before
period
O O O O O O O O O O O
Deep pain with intercourse O O O O O O O O O O O
Pain in groin when lifting O O O O O O O O O O O
Pelvis pain lasting hours or days after intercourse O O O O O O O O O O O
Pain when bladder is full O O O O O O O O O O O
Muscle / joint pain O O O O O O O O O O O
Level of cramps with period O O O O O O O O O O O
Pain after period is over O O O O O O O O O O O
Burning vaginal pain after sex O O O O O O O O O O O
Pain with urination O O O O O O O O O O O
Backache O O O O O O O O O O O
Migraine headache O O O O O O O O O O O
Pain with sitting O O O O O O O O O O O


Information About Your Pain
What types of treatments / providers have you tried in the past for your pain? Please check all that apply.

□ Acupuncture □ Family Practitioner □ Nutrition / diet
□ Anesthesiologist □ Herbal Medicine □ Physical Therapy
□ Anti-seizure medications □ Homeopathic medicine □ Psychotherapy
□ Antidepressants □ Lupron, Synarel, Zoladex □ Psychiatrist
□ Biofeedback □ Massage □ Rheumatologist
□ Botox Injection □ Meditation □ Skin magnets
□ Contraceptive pills / patch / ring □ Narcotics □ Surgery
□ Danazol (Danocrine) □ Naturopathic medication □ TENS unit
□ Depo-Provera □ Nerve blocks □ Trigger point injections
□ Gastroenterologist □ Neurosurgeon □ Urologist
□ Gynecologist □ Nonprescription medicine □ Other _______________________






Patient Name

DOB:

MR #

Index to Questionnaire–Health\Encounter

UWH301896-DT (Rev. 02/10/17) PELVIC PAIN ASSESSMENT Page 2 of 3
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
PELVIC PAIN ASSESSMENT




Pain Maps
Please shade areas of pain and write a number from 1 to 10 at the site(s) of pain. (10 = most severe pain imaginable)






























What physicians or health care providers have evaluated or treated you for chronic pelvic pain?

Physician / Provider Specialty City, State, Phone






Medications
Please list pain medication you have taken for your pain condition in the past 6 months, and the providers who prescribed
them (use separate page if needed):
Medication / dose Provider Did it help?
□ Yes □ No □ Currently taking
□ Yes □ No □ Currently taking
□ Yes □ No □ Currently taking
□ Yes □ No □ Currently taking
□ Yes □ No □ Currently taking
□ Yes □ No □ Currently taking
□ Yes □ No □ Currently taking
□ Yes □ No □ Currently taking
□ Yes □ No □ Currently taking
Left Right Right Left
Vulvar / Perineal Pain
(pain outside and around the vagina and anus)

If you have vulvar pain, shade in the painful areas
and write a number from 1 to 10 at the painful sites.
(10 = most severe pain imaginable)

Is your pain relieved by sitting on a commode seat?
□ Yes □ No
Left Right


Patient Name

DOB:

MR #

Index to Questionnaire–Health\Encounter

UWH301896-DT (Rev. 02/10/17) PELVIC PAIN ASSESSMENT Page 3 of 3
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
PELVIC PAIN ASSESSMENT





Coping Mechanisms
Who are the people you talk to concerning your pain, or during stressful times?
□ Spouse / Partner □ Relative □ Support group □ Clergy
□ Doctor / Nurse □ Friend □ Mental Health provider □ I take care of myself

How does your partner deal with your pain?
□ Doesn’t notice when I’m in pain □ Takes care of me □ Not applicable
□ Withdraws □ Feels helpless
□ Distracts me with activities □ Gets angry

What helps your pain? □ Meditation □ Relaxation □ Lying down □ Music
□ Massage □ Ice □ Heating pad □ Hot bath
□ Pain medication □ Laxatives / Enema □ Injection □ TENS unit
□ Bowel movement □ Emptying bladder □ Nothing
□ Other _____________________________
What makes your pain worse? □ Intercourse □ Orgasm □ Stress □ Full meal
□ Bowel movement □ Full bladder □ Urination □ Standing
□ Walking □ Exercise □ Time of day □ Weather
□ Contact with clothing □ Coughing/sneezing □ Not related to anything
□ Other _____________________________
Of all the problems or stresses of your life, how does your pain compare in importance?
□ The most important problem □ Just one of many problems


Sexual and Physical Abuse History
Have you ever been the victim of emotional abuse? This can include being humiliated or insulted □ Yes □ No □ No answer

Check an answer for both as a child and as an adult
As a child
(13 and younger)
As an adult
(14 and over)
1a. Has anyone ever exposed the sex organs of their body to you when you did not want it? □ Yes □ No □ Yes □ No
1b. Has anyone ever threatened to have sex with you when you did not want it? □ Yes □ No □ Yes □ No
1c. Has anyone ever touched the sex organs of your body when you did not want this? □ Yes □ No □ Yes □ No
1d. Has anyone ever made you touch the sex organs of their body when you did not want this? □ Yes □ No □ Yes □ No
1e. Has anyone forced you to have sex when you did not want this? □ Yes □ No □ Yes □ No
1f. Have you had any other unwanted sexual experiences not mentioned above? □ Yes □ No □ Yes □ No
If yes, please specify __________________________________________________________________________________________

2. When you were a child (13 or younger), did an older person do the following?
a. Hit, kick or beat you? □ Never □ Seldom □ Occasionally □ Often
b. Seriously threaten your life? □ Never □ Seldom □ Occasionally □ Often
3. Now that you are an adult (14 or older), has any other adult done the following?
a. Hit, kick or beat you? □ Never □ Seldom □ Occasionally □ Often
b. Seriously threaten your life? □ Never □ Seldom □ Occasionally □ Often

































































































































© April 2008, The International Pelvic Pain Society

Signature of Patient/Representative _________________________________Date: __________ Time: __________AM/PM


If signed by person other than the patient, print name and state relationship and authority to do so.


Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor  Health Care Agent  Other _____________________


Reviewed by: ___________________________________________________ Date: ______________ Time: __________ AM/PM