BASIC QUESTIONS                           

                                    YOUR RESPONSES

Date of your first menstrual period:

Date of your most recent menstrual period:

Duration of your period:

Type of flow (heavy, medium, light):

Do you have bleeding between periods?

Do you menstruate every 28 to 30 days, or are your cycles irregular? 

What medications, birth control pills, hormones, and/or supplements do you take on a regular basis?

(Note the strength and how often these medications are taken.)

List any previous illnesses (including sexually-transmitted diseases) and surgeries you have had:

ILLNESS OR SURGERY

DATE

List your immediate familys major illnesses and diseases:

List all known allergies:

Do you use tobacco? If yes, how much and how often?

Do you drink alcohol? If yes, how much and how often?

Do you or have you ever used illegal  drugs? If yes, how much and how often?

Do you have pain with your menstrual periods[etj1] ? 

Try to recognise the pattern of your pain. Its important to tell the doctor if you have pain during your menstrual period, all the time, or if it comes and goes. These questions are often best answered by keeping a Daily Pain Journal (see below) that keeps track of the date, the day in your menstrual cycle, the amount of pain youre having, and the duration of the pain (for example, did it last all day or just part of the day?).

 Yes    No    Sometimes

SPECIFIC PAIN QUESTIONS            

                        YOUR RESPONSES

Do you have pain during or after sexual intercourse?

When talking with your doctor about pain with intercourse, be open and honest about the type of pain you have, whether its with deep penetration or all the time, whether orgasm makes the pain worse, and what methods alleviate the pain.

 Yes    No    Sometimes

 Pain is worse with deep penetration

 I have pain during orgasm

 I have pain after orgasm

 I have pain with certain sexual positions

Do you have painful bowel movements?

Many women with endometriosis report significant bowel pain, including painful bowel movements, rectal pain, constipation, or diarrhoea. The doctor will also want to know if youve ever experienced blood in your stool and if any of these symptoms occur during menstruation.

 Yes    No    Sometimes 

 I have painful bowel movements

 I have rectal pain

 I have constipation and/or diarrhoea or alternating courses of both 

 I have had blood in my stool 

 My bowel symptoms are worse during menstruation

Do you have pelvic pain with physical exercise?

Some women with endometriosis report feeling more pain when they engage in strenuous physical exercise. The pain may be more severe during menstruation. 

 Yes    No    Sometimes 

 Pain with exercise is worse during menstruation

When did your pain start?

 Pain started _____ years ago 

 Pain started recently. When? _______________________

Where is the pain?

As you answer this question, point to or describe the area of your body thats affected.

Some physicians will provide a printed diagram of the body so you can mark the areas where you have pain.

Type of pain?

When describing pain, consider which adjectives best describe what you experience. Women often describe endometriosis pain as burning, stabbing, gnawing, cramping, jabbing, throbbing, cold, sharp, aching, or pressure.

Severity of pain?

There are several ways you can describe the pains severity. For example, you may choose to use an adjective, such as excruciating, severe, moderate, or mild. Or you may choose to use a pain scale, rating it on a scale of one (no pain) to ten (pain so severe, it makes you pass out).  If its helpful, you may want to refer to the Andrea Mankoskis Pain Scale (see below). 

Adjective(s) that describe my pain: 

Pain on a scale of 1-10: _____

SPECIFIC PAIN QUESTIONS            

YOUR RESPONSES

How bad is your pain right now?

Be honest!

How many days each month are you in pain? 

If you have a really good memory, you may be able to estimate the number of days youre in pain each month. However, most of us tend to put pain out of our minds after its come and gone, so our estimates arent always accurate. Thats why a Daily Pain Journal is a better way of determining exactly how many days each month you have pain.

Number of days Im in pain per month:  _____

Is the pain getting worse?

From the time the pain started until now, has it gotten worse? If so, by what degree?

 Pain is getting much worse

 Pain is getting somewhat worse

 Pain is about the same as usual

 Pain is getting somewhat better

How does the pain impact your life?

Tell your physician if youre missing work or school or declining invitations due to your symptoms. The doctor will also ask if the pain is preventing you from engaging in sports or exercise. 

List the medications you have taken to try to alleviate your pain. Were these medications effective?

Most women with endometriosis have tried some type of analgesic or anti-inflammatory pain reliever. Tell your doctor of any over-the-counter or prescription medications you have taken or are taking for pain, and whether they reduce your pain levels.

Meds Taken:

Effective?

List any alternative methods you are currently using (or have used) to relieve your pain:

When traditional methods dont work, many women incorporate alternative approaches (such as acupuncture, chiropractic medicine, or biofeedback) to help alleviate their pain. Tell your doctor if you are taking any herbs or seeing alternative practitioners for your pain and whether these methods are effective.

Method:

Effective?

OTHER SYMPTOMS:                          

YOUR RESPONSES:

Do you routinely experience nausea with menstruation?

 Yes    No

Do you vomit during menstruation?

 Yes    No 

Do you have unusual vaginal bleeding at any time during your cycle? 

 Yes    No 

Do you experience painful urination or blood in urine at any time during your cycle?

 Yes    No 

Do you experience bloating during menstruation or at other times?

 Yes    No

Do you have difficulty gaining or losing weight?

 Yes    No 

Do you experience fatigue?

 Yes    No