Pelvic Pain Questionnaire
Please answer each of the questions below.

More information about pelvic congestion syndrome:
https://www.sirweb.org/patient-center/pelvic-congestion-syndrome--chronic-pelvic-pain/
First Name
Your answer
Last Name
Your answer
Phone Number
Your answer
Email Address
Your answer
1. Race
2. Date of Birth
MM
/
DD
/
YYYY
3. Height in Feet and Inches (example: 5'4")
4. Weight (Pounds)
Your answer
5. How many children have you given birth to?
6. In the past 6 months, have you experienced deep, dull, aching pain in your pelvis or lower abdomen?
7. Does the pain worsen during your menstrual period?
8. Does the pain worsen after sexual intercourse?
9. Does the pain worsen after sitting or standing for an extended period of time?
10. Have you been diagnosed with Polycystic Ovary Syndrome(PCOS)?
11. Do you have a history of Varicose Veins in your family?
12. Do you feel heaviness or fullness in your legs?
13. Do you have a frequent urge to urinate?
14. Do you often feel fatigued and lethargic?
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