Quick questions for your upcoming appointment at WHRIA

Thank you for choosing WHRIA to help you restore your health. Please see our website to meet our team before your visit.
Your feedback is important and will help us make the most of your consultation time. Your responses are strictly confidential and will be placed in your file, in accordance with NSW Privacy Legislation.

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* 1. Thank you for your time. Please enter your surname and date of birth below, so your answers can be transferred to your file before your appointment.

Part 1: Pelvic Pain Impact Questionnaire
For each of the following 8 questions, click the circle that best indicates how much your pelvic pain has affected these aspects of your life during the past month. Your answers to these questions can then be summed to give you a final score.
Chalmers, K. J., Catley, M. J., Evans, S. F., & Moseley, G. L. (2017). Clinical assessment of the impact of pelvic pain on women. Pain, 15
In the past month, how much has your pelvic pain affected your:

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* 2. Energy levels?

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* 3. Mood?

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* 4. Sleep?

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* 5. Stomach and intestinal function?

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* 6. Ability to sit for longer than 20 minutes?

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* 7. Ability to perform and function normally at home/work/school/university?

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* 8. Ability to take part in physical activity? (e.g. jogging, yoga, dancing, bicycling)

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* 9. Ability to wear certain clothes? (e.g. underwear, tight fitting clothes)

If the following 2 questions do not apply to you, please select 'This does not apply to me'. These questions will not be added to your summed score.

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* 10. During your last period, how much did your pelvic pain affect your ability to use tampons?

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* 11. In the past month, how much has your pelvic pain affected your levels of intimacy or sexual relations? (e.g. having sex, masturbating)

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* 12. Please list 1-3 activities in your life that you have difficulty doing or can no longer do because of your condition, and would dearly like to return to:

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