Pre-consultation questionnaire

Your symptoms

Please describe your symptoms as you experience them. We are not asking out of curiosity – every answer helps the doctor prepare for your visit.

What are your main symptoms? (optional)

In your own words, bullet points are fine.

At what age did your symptoms start? (optional)

An estimate is enough.

Do you have painful periods?

YES NO

How severe is the pain during your period?

0 0 – no pain

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10 – unbearable pain

0 = no pain 10 = unbearable pain

Do you have painful sexual intercourse?

YES NO

How severe is the pain during intercourse?

0 0 – no pain

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10 – unbearable pain

0 = no pain 10 = unbearable pain

Does your pain get worse after orgasm?

YES NO

How severe is the pain after orgasm?

0 0 – no pain

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10 – unbearable pain

0 = no pain 10 = unbearable pain

Do you have pain when passing stool, especially during your period?

YES NO

How severe is the pain when passing stool?

0 0 – no pain

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10 – unbearable pain

0 = no pain 10 = unbearable pain

During your period, do you have more frequent and looser stools?

YES NO

Do you regularly have blood in your urine?

YES NO

Do you have irregular vaginal bleeding other than ovulation bleeding?

YES NO

Do you regularly have pain after eating?

YES NO

Where do you feel the pain after eating?

Tick all the areas that apply to you.

upper abdomen (below the breastbone) upper right, below the ribs upper left, below the ribs around the navel lower right lower left lower abdomen the whole abdomen

During your period, does the pain radiate into your leg?

NO YES, on the right YES, on the left YES, on both sides

Do you have pain in your lower back?

NO YES, on the right YES, on the left YES, on both sides

During your period, does the pain radiate into your chest or shoulder?

NO YES, on the right YES, on the left YES, on both sides

Do you have any other symptom we have not asked about? (optional)

What you would like help with

What made you seek medical help? You may select more than one option.

What would you like help with?

I would like to get pregnant I would like relief from pain a consultation about an unclear finding from my gynaecologist my own suspicion of endometriosis, without a specialist referral I want help with a different problem

How long have you been trying to conceive?

For example “a year and a half”.

Which pain would you most like relief from? (optional)

What exactly would you like help with?

Have you already had an endometriosis consultation at another endometriosis centre?

If so, please bring the examination report with you.

YES NO

Have you had an MRI scan for suspected endometriosis?

If so, please arrange with the facility where the examination was performed to send the images via PACS to the hospital in Frýdek-Místek.

YES NO

Have you already had surgery for endometriosis?

If so, please bring the surgical report to the examination.

YES NO

Where was the surgery performed?