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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