Endo Clinic Patient Form

General Patient Information
Patient Name*

PrefixFirst NameMiddle NameLast Name
Do you identify as Aboriginal or Torres Strait Islander?

AboriginalTorres Strait IslanderBothNeither
Please enter your email address
example@example.com
Please enter your Medicare Number
Medicare Expiry Date (format MMYYYY)
Your position on the Medicare card
Date of Birth (DD-MM-YYYY)

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number
Please enter a valid mobile phone number.
Do you currently have a Health Care Concession Card?

YesNo
Next of Kin Details

First NameLast Name
Next of Kin Mobile Phone Number
Please enter a valid phone number.
Relationship to you
Please list your current GP, their address and contact number
Patient Medical History
Please give a brief outline of your Endometriosis/Pelvic pain symptoms
Please list any Surgical Procedures you have undergone for Endometriosis and the dates of each
Please list your Current Regular Medications
Please list any medications you have been prescribed specifically in relation to your Endometriosis or Pelvic Pain
Please select any of the following specialists you have seen in regards to your Endometriosis or Pelvic Pain

Pelvic Floor PhysiotherapistPain SpecialistGynecologistDietitianNaturopathPsychologistColorectal Surgeon
In the past month, how much has your pelvic pain affected your energy levels?

Not at allA little bitSomewhatQuite a bitA great deal
In the past month, how much has your pelvic pain affected your mood

Not at allA little bitSomewhatQuite a bitA great deal
In the past month, how much has your pelvic pain affected your sleep?

Not at allA little bitSomewhatQuite a bitA great deal
In the past month, how much has your pelvic pain affected your ability to take part in physical activity?

Not at allA little bitSomewhatQuite a bitA great deal
Do you have any other medical conditions?
Do You have any of the following symptoms? (Select all that apply)

FatiguePoor sleepDizzinessAnxietyNauseaLow mood
Endometriosis Health Profile Questionaire
During the last 4 weeks, how often, because of your emdometriosis or pelvic pain, have you.....
Been unable to go to social events because of the pain?

NeverRarelySometimesOftenAlways
Been unable to do jobs around the home because of pain?

NeverRarelySometimesOftenAlways
Found it difficult to stand because of the pain?

NeverRarelySometimesOftenAlways
Found it difficult to sit because of the pain?

NeverRarelySometimesOftenAlways
Found it difficult to walk because of the pain?

NeverRarelySometimesOftenAlways
Found it difficult to exercise or do leisure activities you would like to do because of the pain?

NeverRarelySometimesOftenAlways
Lost your appetite and/or been unable to eat because of the pain?

NeverRarelySometimesOftenAlways
Been unable to sleep properly because of the pain?

NeverRarelySometimesOftenAlways
Had to go to bed/lie down because of the pain?

NeverRarelySometimesOftenAlways
Been unable to do the things you want to do because of the pain?

NeverRarelySometimesOftenAlways
Felt unable to cope with the pain?

NeverRarelySometimesOftenAlways
During the last 4 weeks, how often, because of your endometriosis or pelvic pain, have you
Generally felt unwell?

NeverRarelySometimesOftenAlways
Felt frustrated because your symptoms are not getting better?

NeverRarelySometimesOftenAlways
Felt frustrated because you are not able to control your symptoms?

NeverRarelySometimesOftenAlways
Felt unable to forget your symptoms?

NeverRarelySometimesOftenAlways
Felt as though your symptoms are ruling your life?

NeverRarelySometimesOftenAlways
Felt your symptoms are taking away your life?

NeverRarelySometimesOftenAlways
During the last 4 weeks, how often, because of your endometriosis or pelvic pain, have you...
Felt depressed?

NeverRarelySometimesOftenAlways
Felt weepy/tearful

NeverRarelySometimesOftenAlways
Felt miserable?

NeverRarelySometimesOftenAlways
Had mood swings?

NeverRarelySometimesOftenAlways
During the last 4 weeks, how often, because of your endometriosis or pelvic pain, have you ...
Felt bad tempered or short tempered?

NeverRarelySometimesOftenAlways
Felt violent or aggresive?

NeverRarelySometimesOftenAlways
Felt unable to tell people how you feel?

NeverRarelySometimesOftenAlways
Felt others do not understand what you are going through?

NeverRarelySometimesOftenAlways
Felt as though others think you are moaning?

NeverRarelySometimesOftenAlways
Felt alone?

NeverRarelySometimesOftenAlways
During the last 4 weeks, how often, because of your endometriosis or pelvic pain, have you ...
Felt frustrated as you cannot always wear the clothes you would choose?

NeverRarelySometimesOftenAlways
Felt your appearance has been affected?

NeverRarelySometimesOftenAlways
Lacked confidence?

NeverRarelySometimesOftenAlways
Health Questionnaire (EQ-5D-5L)

Under each heading, please tick the ONE box that best describes your health TODAY
Mobility

I have no problems in walking aboutI have slight problems in walking aboutI have moderate problems in walking aboutI have severe problems in walking aboutI am unable to walk about
Self -Care

I have no problems washing or dressing myselfI have slight problems washing or dressing myselfI have moderate problems washing or dressing myselfI have severe problems washing or dressing myselfI am unable to wash or dress myself
Usual Activities

I have no problems doing my usual activitiesI have slight problems doing my usual activitiesI have moderate problems doing my usual activitiesI have severe problems doing my usual activitiesI am unable to do my usual activities
Pain/Discomfort

I have no pain or discomfortI have slight pain or discomfortI have moderate pain or discomfortI have severe pain or discomfortI have extreme pain or discomfort
Anxiety / Depression

I am not anxious or depressedI am slightly anxious or depressedI am moderately anxious or depressedI am severely anxious or depressedI am extremely anxious or depressed
We would like to know how good or bad your health is TODAY.

This scale is numbered from 0 to 100.

100 means the best health you can imagine.

0 means the worst health you can imagine.

Please write the number below to indicate your health score out of 100 TODAY.
Enter a number from 0 to 100
In order for us to assess your requirements and create a personal management plan, please list the top 3 goals you would like to achieve through attending the Hunters Hill Endometriosis and Pelvic Pain clinic
Goal 1:
Goal 2:
Goal 3:
Confidentiality and Privacy

Our practice will need to collect your personal information to provide healthcare services to you. Such information may need to be shared with other healthcare providers to facilitate your care. HHMP maintains all medical records under strict confidentiality in accordance with all Commonwealth Privacy Legislation. For more information, please refer to our privacy policy located at reception.
We may need to contact one or more of your current healthcare providers to access your medical records. This information will enable us to provide you with a more appropriate and effective treatment plan.
I consent to Hunters Hill Medical Practice contacting my health providers and accessing my medical records

I DO consentI DO NOT consent
I consent to being contacted via SMS, phone and/or email for appointment confirmations, reminders, practice updates and health information

SMSPhone (non urgent)Email
Thank you for completing this information. Your answers will be compiled and our Endometriosis nurse will contact you in the next few days to arrange your first clinic appointment.
Should be Empty:

General Patient Information

Patient Medical History

Endometriosis Health Profile Questionaire

During the last 4 weeks, how often, because of your emdometriosis or pelvic pain, have you.....

During the last 4 weeks, how often, because of your endometriosis or pelvic pain, have you

During the last 4 weeks, how often, because of your endometriosis or pelvic pain, have you...

During the last 4 weeks, how often, because of your endometriosis or pelvic pain, have you ...

During the last 4 weeks, how often, because of your endometriosis or pelvic pain, have you ...

Health Questionnaire (EQ-5D-5L)

In order for us to assess your requirements and create a personal management plan, please list the top 3 goals you would like to achieve through attending the Hunters Hill Endometriosis and Pelvic Pain clinic

Thank you for completing this information. Your answers will be compiled and our Endometriosis nurse will contact you in the next few days to arrange your first clinic appointment.