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Initial History and Physical Exam
Is there an alternate contact if we cannot reach you? Information About Your PainPlease describe your pain problem: What do you think is causing your pain? What does your family think is causing your pain? Do you think anyone is to blame for your pain? q Yes q No If so, who? Do you think surgery will be necessary? q Yes q NoIs there an event that you associate with the onset of pain? q Yes q No If so, what? How long have you had this pain? q < 6 months q 6 months – 1 year q 1 – 2 years q > 2 years For each of the symptoms listed below, please “bubble in” your level of pain over the last month using a 10-point scale: Pelvic pain lasting hours or days after intercourse What would be an acceptable level of pain? October 2007, The International Pelvic Pain Society This document may be freely reproduced and distributed as long as this copyright notice remains intact Demographic InformationAre you (check all that apply): What kind of work are you trained for? What type of work are you doing? Health HabitsDo you get regular exercise? q Yes q No What is your diet like? What is your caffeine intake (number per day, include coffee, tea, soft drinks, etc.)? q 0 q 1–3 q 4–6 q >6 How many cigarettes do you smoke per day? Have you ever felt the need to cut down on your drinking? q Yes q NoHave you ever felt annoyed by criticism of your drinking? q Yes q NoHave you ever felt guilty about your drinking, or about something you said or did while you were drinking? q Yes q NoHave you ever taken a morning “eye-opener” drink? q Yes q No What is your use of recreational drugs? q Never used q Used in past, but not now q Presently using q Choose not to answer Have you ever received treatment for substance abuse? q Yes q No Coping MechanismsWho are the people you talk to concerning your pain, or during stressful times? How does your partner deal with your pain? q Contact with clothing q Coughing/sneezing Of all of the problems or stresses in your life, how does your pain compare in importance? 2007, The International Pelvic Pain Society How old were you when your menses started? Are you still having menstrual periods? q Yes q No Answer the following only if you are still having menstrual periods:
Does pain start the day flow starts? q Yes q No Starts days before flow starts: q Yes q No Do you pass any clots in menstrual flow? q Yes q No BladderDo you experience any of the following: Loss of urine when coughing, sneezing, or laughing? q Yes q NoFrequent urination? q Yes q NoNeed to urinate with little warning? q Yes q NoDifficulty passing urine? q Yes q NoFrequent bladder infections? q Yes q NoFrequency of nighttime urination: q 0–1 q 2 or more Frequency of daytime urination: q 8 or less q 9–15 q >16 Do you still feel full after urination? q Yes q No Is there discomfort or pain associated with a change in the consistency of the stool (i.e., softer or harder) ? q Yes q NoWould you say that at least one-fourth (_) of the occasions or days in the last 3 months you have had any of the following (Check all that apply)q Fewer than three bowel movements a week (0–2 bowel movements)q More than three bowel movements a day (4 or more bowel movements)q Hard or lumpy stoolsq Loose or watery stoolsq Straining during a bowel movementq Urgency – having to rush to the bathroom for a bowel movementq Feeling of incomplete emptying after a bowel movementq Passing mucus (white material) during a bowel movementq Abdominal fullness, bloating, or swelling 1 The Functional Gastrointestinal Disorders, Drossman, et al. Chapter 4, “Functional Bowel Disorders and Functional Abdominal Gastrointestinal/EatingDo you have nausea? Have you ever had an eating disorder such as anorexia or bulimia? q Yes q No 2007, The International Pelvic Pain Society Short-Form McGillThe words below describe average pain. Place a check mark (ü) in the column which represents thedegree to which you feel that type of pain. Please limit yourself to a description of the pain in yourpelvic area only.
Type
None (0)
Mild (1)
Moderate (2)
Severe (3)
Melzack, R: The Short-Form McGill Pain Questionnaire, Pain 30:191–197, 1987 Which statement(s) below best describes how you cope with the pain? Check all that apply q I count numbers in my head or run a song through my mind q I tell myself to be brave and carry on despite the pain q I just think of it as some other sensation, such as numbness q I tell myself that it really doesn’t hurt q I worry all the time about whether it will end q I do something active, like household chores or projects SF-36In general, would you say your health is: Compared to one year ago, how would you rate your health in general now? The following items are about activities you mightdo during a typical day. Does your health now limityou in these activities? If so, how much? Vigorous activities, such as running, lifting heavy object, participating in strenuous sports Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf 2007, The International Pelvic Pain Society During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities because of yourphysical health? Cut down the amount of time you spent on your work or other activities ¡ Yes Accomplish less than you would like ¡ Yes Were limited in the kind of work or other activities ¡ Yes Had difficulty performing the work or other activities (for example, it took extra effort) ¡ Yes During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities because of anyemotional problems (such as feeling depressed or anxious)? Cut down the amount of time you spent on work or other activities ¡ Yes Accomplished less than you would like ¡ Yes Didn’t do work or other activities as carefully as usual ¡ Yes During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activitieswith family, friend, neighbors, or groups? How much bodily pain have you had during the past 4 weeks? During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? These questions are about how you feeland how things have been with youduring the past 4 weeks. For eachquestion, please give the one answer thatcomes closest to the way you have beenfeeling. How much of the time duringthe past 4 weeks: During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities(like visiting with friends, relatives, etc.? ¡ Some of the time ¡ A little of the time ¡ None of the time How TRUE or FALSE is each of the followingstatements for you? I seem to get sick a little easier than other people 2007, The International Pelvic Pain Society Personal HistoryWhat would you like to tell us about your pain that we have not asked? Comments: What types of treatments have you tried in the past for this pain? q Acupuncture q Homeopathic medicine q Physical What physicians or health care providers have evaluated or treated you for chronic pelvic pain? Include all healthcare professionals,whether they were physicians or not. Do you have any objections to me contacting these healthcare providers? q Yes q No Physician/Provider
City, State
Please list all surgical procedures you’ve had (related to this pain):
Year
Procedure
Surgeon
Please list all other surgical procedures: Year
Procedure
Year
Procedure
Please list pain medications you’ve taken for your pain condition in the past 6 months, and the physicians who prescribed them (useseparate page if necessary): Medication
Physician
Did it help?
q Yes q Noq Yes q Noq Yes q Noq Yes q Noq Yes q Noq Yes q Noq Yes q No q I have written more medications on a separate page 2007, The International Pelvic Pain Society Have you ever been hospitalized for anything besides surgery or childbirth? q Yes q No Have you had major accidents such as falls or back injury? q Yes q NoHave you ever been treated for depression? q Yes q No Treatments: q Medication q Hospitalization q Psychotherapy How many pregnancies have you had? Resulting in (#): Full 9 month Any complications during pregnancy, labor, delivery, or post partum period? Place an “X” at the point of your most intense pain.
Shade in all other painful areas.
2007, The International Pelvic Pain Society Sexual and Physical Abuse HistoryHave you ever been the victim of emotional abuse? This can include being humiliated or insulted. q Yes q No q No answer Circle an answer for both as a child and as an adult.

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