To be printed on headed paper
PELVIC PAIN ASSESSMENT
Form No. 02(b) – Patient re-entry
This questionnaire is designed to help you describe your pain symptoms and your health, and how
these impact on your life in general.
Please read through the instructions at the beginning of each section carefully. For most questions, all
you need to do is tick the appropriate box that best describes how you feel.
There are no right or wrong answers. We are just interested in your own views about your health, your
pain symptoms and how you feel about life in general. Try not to dwell too long on any question, and
choose the answer that comes closest to how you have been feeling generally.
Please try to answer as many of the questions as possible, even if some may seem repetitive or less
relevant. There are some sensitive questions but you can choose to miss out any question you do not
feel comfortable answering.
Your doctor or nurse who looks at this may make some extra notes on the blank sections marked for
them. If you have any queries about the form, your doctor or nurse will be able to help you with them.
For any symptoms other than pain, be sure to discuss these with the doctor or nurse you are seeing.
NHS Number
GP’s Name
GP Practice
For completion by clinician:
Recruited to MEDAL study YES / NO
If Yes, Study Number:
Hospital Name................................................
Clinician Name: ..........................................................
Clinician Signature: ....................................................
Date:
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
D
D
Page 1 of 15
M
M
M
Y
Y
Y
Y
Version 2.1 - 27th November 2012
1. ABOUT YOUR PAIN PROBLEMS
Please describe your pain problems, with the most troublesome problem first.
1. __________________________________________________________
2.___________________________________________________________
3.___________________________________________________________
4.___________________________________________________________
5.___________________________________________________________
What do you think is causing your pain?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Since your previous visit, overall has the pain? (please tick one box)
Got a lot worse Got a little worse Not changed Got a little better
Got a lot better
Don’t know
For approximately how long in total did you have pelvic pain in the last 3 months? (please tick one box)
Less than one day a month
One day a month
2 – 3 days a month
One day a week
More than one day a week
Every day
Space for Doctor’s notes
2
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
2. ABOUT YOUR PAIN
Please shade areas of pain and write a number from 1 to 10 at the site(s)
of the pain. (10 = most severe pain imaginable
1. Left upper back quadrant
2. Central upper back
3. Right upper back quadrant
4. Left lumbar back region
5. Central back
6. Right lumbar back region
7. Left lower back region
8. Central lower back
9. Right lower back
10. Left outer posterior thigh
11. Left inner posterior thigh
12. Right inner posterior thigh
13. Right outer posterior thigh
14. Right hypochondriac upper
15. Epigastric region
16. Left hypochondriac upper
17. Right lumbar
18. Umbilical region
19. Left lumbar
20. Right Iliac
21. Hypogastric/ Suprapubic
22. Left Iliac
23. Right outer anterior thigh
24. Right inner anterior thigh
25. Left inner anterior thigh
26. Left outer anterior thigh
27. Urethral region
28. Vuval
29. Perianal
30. Right inner thigh
31. Right buttock
32. Left inner thigh
33. Left buttock
Vulval/Perineal Pain
(Pain outside and around the Vagina and
Anus)
If you have Vulval pain, shade the painful
areas and write a number from 1 to 10 at the
painful sites (10 = most severe pain
imaginable)
Right
Left
Right
Right
Left
Left
Space for Doctor’s notes
3
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
3. ABOUT YOUR PAIN
There are many types of pain. For each of those list below, please circle the number that best describes your
average level of pain over the last month. Also say roughly how many months you have had each type of pain.
For example
Pain just before period
No Pain
Worst pain imaginable
Duration
(months)
Now please consider your pain problems. How do you rate your pain, on average?
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Pain just before period
No Pain
Pain during period
No Pain
Pain when period is over
No Pain
Pain mid-cycle
No Pain
If you did not have sexual intercourse in the last month, please tick box
and skip this section to go to the next page
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Pain at the point of vaginal penetration
No Pain
Deep pain during intercourse
No Pain
Burning vaginal pain during intercourse
No Pain
Pelvic pain lasting hours or days after
No Pain
Space for Doctor’s notes
4
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
Other types of pelvic pain in the last month
By ‘Pelvic pain’ we mean any type of pain in the lower part of your belly (in the area from your navel down).
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Worst pain imaginable
Duration
(months)
Pain when bladder is full
No Pain
Pain with urination
No Pain
Muscle/joint pain in pelvis
No Pain
Pain in pelvis when lifting
No Pain
Pain with sitting
No Pain
Backache
No Pain
Migraine headache
No Pain
4.
DESCRIBING YOUR PAIN
The words below describe average pain. Place a tick ( ) in the box which represents the degree to which
you feel that type of pain. Please limit yourself to a description of the pain in your pelvic area only.
NONE
MILD
MODERATE
SEVERE
What does your pain feel like?
0
Throbbing
Shooting
Stabbing
Sharp
Cramping
Gnawing
Hot-burning
Aching
Heavy
Tender
Splitting
Tiring-exhausting
Sickening
Fearful
Punishing-cruel
1
2
3

Melzak R. The Short-form McGill Pain Questionnaire. Pain 1987;30:191-197.
Space for Doctor’s notes
5
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
5. CURRENT MEDICATION
Space for Doctor’s notes
6. TREATMENTS FOR PAIN
What types of treatments have you tried in the past for your pain? (please indicate with a tick)
No
Yes
If yes, was it
helpful?
No
Yes
No
Acupuncture
Massage
Anti-seizure medications
Antidepressants
Meditation or
relaxation exercises
Strong painkillers
Biofeedback
Nerve blocks
Botox injection
Non-prescription
medicine
Nutrition/diet
Contraceptive pills/patch/
ring
Exercise, yoga or pilates
Yes
If yes, was it
helpful?
No
Yes
Physiotherapy
Hormonal therapy for
endometrisosis
Herbal Medicine
Psychological
(talking) therapy
TENS
Homeopathic medicine
Other – please state
.................................
Space for Doctor’s notes
6
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
7. ABOUT YOUR PERIODS
Are you still having menstrual periods?
Date of first day of last period? DD DYYY
D
No
M
Yes
M
M
Y
Y
Y
Y
Answer the following only if you are still having menstrual periods:
(please tick one box in each section)
In the last three months, have you had pelvic pain with your periods?
No
Occasionally (with 1 in 3 of my periods)
Often (with 2 in 3 of my periods)
Always (every period)
In the last three months, have you had pelvic pain at times other than with periods or sexual intercourse?
No
Yes, just before a period
Yes, just after a period
How regular are your periods?
Regular, I know when to expect my period
Fairly regular, my period starts within a few days of when I expect
Irregular, I cannot predict when my period will start
I have bleeding on and off all the time
My periods are: Light
Moderate
Heavy
How many days of bleeding do you usually have each period?
(We mean bleeding for which you need a tampon or sanitary
pad, NOT discharge for which you needed a panty liner only)
Bleed through protection
_________ days
How many days between the start of one period and the start of next, on average?
Do you pass clots in menstrual flow? No
Yes
Does pain start the day flow starts?
Yes
No
________ days
Pain starts ________ days before flow
Space for Doctor’s notes
7
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
8. PREVIOUS DIAGNOSIS
Has a doctor ever given you a diagnosis of any of the following? (please indicate with a tick)
No
Yes
Endometriosis
Adhesions
Fibroids
Adenomyosis
Uterine Polyps
Ovarian cysts
Appendicitis
Hernia
Infertility or low fertility
No
Yes
Uterine or bladder prolapse
Vulva pain/Vulvodynia
Irritable bowel syndrome
Nerve entrapment in pelvis/pudendal neuropathy
Fibromyalgia
Painful bladder syndrome (interstitial cystitis)
Sexually transmitted infection
Female circumcision/cutting

Space for Doctor’s notes
9. PREVIOUS TESTS
Have you ever had a cervical
screening (smear) test?
No
If yes, what the outcome?
Normal
Have you ever had a Chlamydia test?
No
Yes
If yes, when was your last test (roughly)?
Abnormal changes
Yes
If yes, when was your last test (roughly)?
If yes, what the outcome?
No Chlamydia
10.
Treated for Chlamydia
Chlamydia but was not treated
PREVIOUS INVESTIGATIONS/OPERATIONS
Which of the following previous investigations have you had for pelvic pain? (please indicate with a tick)
No Yes
No Yes
Laparoscopy (telescope examination through belly)
Laparotomy (open surgery)
Cystoscopy (telescope examination of the bladder)
Ultrasound via vagina
Colonoscopy (telescope examination of the bowel)
Ultrasound on abdomen
Hysteroscopy (telescope examination via the vagina)
Nerve transmission test
Magnetic resonance (MRI) scan
Allergy tests

Other – please state...........................
Space for Doctor’s notes
8
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
11.
ABOUT CONTRACEPTION
Are you sexually active?
Are you trying for a baby?
No
No
Yes
Yes
If yes, please answer the question about contraception
If yes, please go to section 14
If you are using contraception, please tick all the methods of contraception you use:
No
Yes
Patch
Female sterilisation (clips)
Implant
Female sterilisation (implants)
Coil (Mirena)
Male partner sterilisation
Condom
Contraceptive pill
Diaphragm/cap
Mini-pill
Vaginal ring
Injection
Natural method
12.
No
Yes
FERTILITY
Are you currently trying to get pregnant?
(please tick one box)
No
Yes, trying for less than a year
Yes, trying for more than a year
13.
OTHER RECENT MEDICAL HISTORY
Space for Doctor’s notes
9
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
14.
BOWEL SYMPTOMS
Do you ever experience rectal bleeding or blood in your stool during your period
Yes
No
Do you have problems with recurrent pain or discomfort in your abdomen? (please indicate/ tick
More than 1 year
More than 6 months
Last month only
No
)


Considering the past 3 months, how often have you had pain or discomfort in the abdomen?
(please indicate/ tick
All of the time
)
Most days of the
month
At least 3 days per
month
1 day per month
Never
If you have had abdominal pain or discomfort, is this associated with any of the following
Improvement on going to the toilet to pass stool
Yes
No
A change in how often you go to the toilet
Yes
No
A change in the appearance (form) of the stool:
Yes
No
Rome Foundation Inc. Gastroenterology 2006;20(5):1377-90.
Space for doctor’s notes
10
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
15.
URINARY PROBLEMS
The following questions are about going to the toilet for a wee. This is also called voiding.
Some women sometimes feel a sudden, overwhelming need to go to the toilet. This is called urgency.
For each of the following questions, please circle the answer that best describes how you feel.
1
2a
2b
3
4a
How many times do you void (go
for a wee) during waking hours?
How many times do you void at
night?
If you get up at night, to what
extent does it usually bother you?
Are you currently sexually active?
Yes
No
IF YOU ARE SEXUALLY ACTIVE,
do you now, or have you ever had,
pain or urgency to urinate during or
after sexual intercourse?
4b
Has the pain or urgency ever made
you avoid sexual intercourse?
5
Do you have pain associated with
your bladder or in your pelvis,
vagina, lower abdomen, urethra
(the opening from which you wee)
or perineum (the area between
your front and back passage)?
6
Do you still have urgency shortly
after urinating?
7a
When you have pain, is it usually?
7b
How often does this pain bother
you?
8a
When you have urgency, it is
usually?
8b
How often does this bother you?
0
1
2
3
4
3-6
7-10
11-14
15-19
20+
0
1
2
3
4+
Never
Mildly
Moderate
Severe
Never
Occasionally
Usually
Always
Never
Occasionally
Usually
Always
Never
Occasionally
Usually
Always
Never
Occasionally
Usually
Always
Mild
Moderate
Severe
Occasionally
Usually
Always
Mild
Moderate
Severe
Occasionally
Usually
Always
Never
Never
Parsons C.L. J Reprod Med 2004;49(Supplement 3):235-42.
Yes
No
Do you suffer from pain when your bladder is filling?
Space for doctor’s notes
11
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
16.
ASSESSMENT OF SEXUAL ACTIVITY
Although the following questions are sensitive and personal, they are important in determining how
different tests and treatments affect this part of your life. Please be assured that your responses
to these questions will remain confidential. We understand if you would rather not answer these.
Yes
No
A)
Are you currently married or having an intimate relationship with someone?
Have you changed your sexual partner in the last 6 months?
Do you engage in sexual activity with anyone at the moment?
If no to this question, please answer section B)
If yes to this question, please go to the section C)
B)
I am not sexually active at the moment because: (Please tick as many of these items as apply)
I do not have a partner at the moment
I am not interested in sex
I am too tired
My partner is not interested in sex
My partner is too tired
I have a physical problem which makes sexual relations difficult or uncomfortable
My partner has a physical problem which makes sexual relations difficult or uncomfortable
Other reasons (please describe) …………………………………
C) Please complete this section if you are sexually active.
Please read each of the following questions carefully and tick the box that best indicates your sexual
feelings and experiences during the past month.
Very
Somewhat
A little
Not at
During the past month:
much
all
Was ‘having sex’ an important part of your life this month?
Did you enjoy sexual activity this month?
In general, were you too tired to have sex?
Did you desire to have sex with your partner(s) this month?
During sexual relations, how frequently did you notice dryness of
your vagina this month?
Did you feel pain or discomfort during penetration this month?
In general, did you feel satisfied after sexual activity this month?
5 times
or more
3-4 times
1-2
times
Not at
all
How did this frequency of sexual activity compare with what is
usual for you?
Much
more
Somewhat
more
About
the
same
Less
than
usual
Were you satisfied with the frequency of sexual activity this
month?
Very
much
Somewhat
A little
Not at
all
How often did you engage in sexual activity this month?
Stead M.L. et al. Br J Obstet Gynaecol 1999;106(1):50-4.
Space for doctor’s notes
12
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
17.
HOW DO YOU COPE WITH PAIN?
Over the last month, how often have you:
Found it difficult to walk because of the pain
Felt as though symptoms were ruling your life
Have had mood swings
Felt others do not understand what you are going through
Felt your appearance has been affected
Never
Rarely Sometimes
Often
Always
Jones et al. Quality of Life Research 2004; 13:695 -704
Of all the problems and stresses in your life, how does your pain compare in importance?
Please make a mark on the line to describe your pain
Just one of
The most important
thing
many problems
Over the last two weeks, how often have you been bothered by the following? (please indicate
0
1
2
3
Not at all
)
Several days More than half the days Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Kroenke et al Med Care 2003,41:1284 - 1292
Space for Doctor’s notes
13
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
18.
GENERAL QUALITY OF LIFE
By placing a tick in one box in each group below left, please indicate which statements best
describe your own health state today.
Mobility
I have no problems in walking about
I have some problems in walking about
I am confined to bed
Self-Care
I have no problems with self-care
I have some problems washing or dressing myself
I am unable to wash or dress myself
Usual Activities (e.g. work, study, housework, family
or leisure activities)
I have no problems with performing my usual activities
I have some problems with performing my usual
activities
I am unable to perform my usual activities
Pain/Discomfort
I have no pain or discomfort
I have moderate pain or discomfort
Please draw
a line on the
thermometer
to show how
you rate your
state of
health today
I have extreme pain or discomfort
Anxiety/Depression
I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed
The EuroQol Group. Health Policy 1990;16(3):199-208.
14
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012
By placing a tick in one box in each group below, please indicate which statements best describe
your own health state today:
1. Mobility
I have no problems in walking about
I have some problems in walking about
I am confined to bed
2. Self-Care
I have no problems with self-car
I have some problems washing or dressing myself
I am unable to wash or dress myself
3. Usual Activities (e.g. work, study, housework, family, leisure activities)
I have no problems with performing my usual activities
I have some problems with performing my usual activities
I am unable to perform my usual activities
4. Achievement and progress
I can achieve and progress in all aspects of my life
I can achieve and progress in many aspects of my life
I can achieve and progress in a few aspects of my life
I cannot achieve and progress in any aspects of my life
5. Enjoyment and pleasure
I can have a lot of enjoyment and pleasure
I can have quite a lot of enjoyment and pleasure
I can have a little enjoyment and pleasure
I cannot have any enjoyment and pleasure
ICECAP-A measure V2 © 2010 Hareth Al-Janabi and Joanna Coast
15
PELVIC PAIN ASSESSMENT - Form 2(b) Patient re-entry
Version 2.1 - 27th November 2012