Hunters Hill Endometriosis Clinic – Patient Intake Questionnaire

Hunters Hill Endometriosis Clinic – Patient Intake Questionnaire

Please complete this patient intake questionnaire using the exact fields and layout from the uploaded reference PDF.
Personal Details
Full Name

First NameMiddle NameLast Name
Date of Birth (DD/MM/YYYY)

DayMonthYear
Date
Email Address
example@example.com
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Residential Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Aboriginal / Torres Strait Islander Status
Medicare Number
Your position on the Medicare card
Medicare Expiry Date
Do you hold a concession card?
Next of Kin Details
Next of kin name

First NameLast Name
Relationship to you
Contact number
Please enter a valid phone number.Format: (000) 000-0000.
GP / Referring Doctor Information
GP / Referring Doctor Name

First NameLast Name
Practice Name
Practice Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Endometriosis / Pelvic Pain History
Have you been diagnosed with endometriosis?
Please give a brief outline of your Endometriosis/Pelvic Pain symptoms
Have you previously had surgery for endometriosis or pelvic pain?
Please give a brief outline of your Endometriosis/Pelvic Pain symptoms
Medication History
Please list your current regular medications
Please list any medications you have been prescribed specifically in relation to your Endometriosis or Pelvic Pain
Pelvic Pain Impact Questionnaire (PPIQ)
1. My pain has stopped me from doing things at home.

0

1

2

3

4

0 is Not at all, 4 is A great deal
2. My pain has stopped me from doing things with my family or friends.

0

1

2

3

4

0 is Not at all, 4 is A great deal
3. My pain has stopped me from doing things at work or study.

0

1

2

3

4

0 is Not at all, 4 is A great deal
4. My pain has stopped me from doing exercise or sport.

0

1

2

3

4

0 is Not at all, 4 is A great deal
5. My pain has stopped me from doing things for myself.

0

1

2

3

4

0 is Not at all, 4 is A great deal
6. My pain has stopped me from doing things I enjoy.

0

1

2

3

4

0 is Never, 4 is Always
7. My pain has stopped me from sleeping properly.

0

1

2

3

4

0 is Not at all, 4 is A great deal
8. My pain has stopped me from doing household tasks.

0

1

2

3

4

0 is Not at all, 4 is A great deal
Which of the following activities has your pain affected?

Other
Which of the following best describes when your pain affects you most?

Other
Patient Goals

In order for us to assess your individual requirements and develop a personalised management plan, please tell us the three most important goals you would like to achieve through attending the Hunters Hill Endometriosis Clinic.
Patient Goal 1
Patient Goal 2
Patient Goal 3
How did you hear about the Endometriosis Clinic at Hunters Hill Medical Practice?

Other
Consent and Declaration
Consent to access health information
Consent to electronic communication
Should be Empty:

Hunters Hill Endometriosis Clinic – Patient Intake Questionnaire

Personal Details

Next of Kin Details

GP / Referring Doctor Information

Endometriosis / Pelvic Pain History

Medication History

Pelvic Pain Impact Questionnaire (PPIQ)

Patient Goals

Consent and Declaration