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Initial History and Physical Examination Date:___________________________ This assessment form is intended to assist the clinician with the initial patient assessment and is not meant to be a diagnostic tool. Contact Information Name:___________________________________ Birth Date:_________________ Phone: Work: ____________________________ Referring Provider’s Name and Address: __________________________________________________________________ Information About Your Pain Please describe your pain problem (use a separate sheet of paper if needed) :_______________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ What do you think is causing your pain?____________________________________________________________________ Is there an event that you associate with the onset of your pain? Yes No If so, what?_________________________ How long have you had this pain? ____ years ____ months For each of the symptoms listed below, please “bubble in” your level of pain over the last month using a 10-point scale: 0 - no pain 10 – the worst pain imaginable intercourse Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Pelvic pain lasting hours or days after intercourse urination Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Backache Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Migraine headache Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Provider Comments ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ April 2008, The International Pelvic Pain Society This document may be freely reproduced and distributed as long as this copyright notice remains intact What types of treatments / providers have you tried in the past for your pain? Please check all that apply.
Pain Maps Please shade areas of pain and write a number from 1 to 10 at the site(s) of pain. (10 = most severe pain imaginable) Vulvar / Perineal Pain (pain outside and around the vagina and anus) If you have vulvar pain, shade the painful areas and write a number from 1 to 10 at the painful sites. (10 = most severe pain imaginable) Is your pain relieved by sitting on a commode seat? April 2008, The International Pelvic Pain Society This document may be freely reproduced and distributed as long as this copyright notice remains intact
What physicians or health care providers have evaluated or treated you for chronic pelvic pain?
Physician / Provider
Specialty
City, State, Phone
Demographic Information Are you (check all that apply): Who do you live with? _____________________________________________________________________________ Education: What type of work are you trained for? ________________________________________________________________ What type of work are you doing? ____________________________________________________________________
Surgical History
Please list all surgical procedures you have had related to this pain:
Year

Please list all other surgical procedures:
Provider Comments _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ April 2008, The International Pelvic Pain Society This document may be freely reproduced and distributed as long as this copyright notice remains intact
Medications
Please list pain medication you have taken for your pain condition in the past 6 months, and the providers who prescribed them
(use a separate page if needed):
Medication / dose
Please list all other medications you are presently taking, the condition, and the provider who prescribed them (use a separate page if
needed):
Medication / dose
Obstetrical History How many pregnancies have you had? ________ Resulting in (#): ____ Full 9 months ____ Premature ____ Miscarriage / Abortion ____ Living children Where there any complications during pregnancy, labor, delivery, or post partum? Medication for bleeding Other _________________ Family History Has anyone in your family had: Endometriosis Cancer, Type(s) _____________________________________ Medical History Please list any medical problems / diagnoses _________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Allergies (including latex allergy) _________________________________________________________________________ Who is your primary care provider? _______________________________________________________________________ Have you ever been hospitalized for anything besides childbirth? Yes No If yes, please explain____________ _________________________________________________________________________________________________ Have you had major accidents such as falls or a back injury? Yes No Have you ever been treated for depression? Yes No Treatments: Medication Hospitalization Psychotherapy Birth control method: Nothing Pill Vasectomy Vaginal ring Depo provera Condom IUD Hysterectomy Diaphragm Tubal Sterilization April 2008, The International Pelvic Pain Society This document may be freely reproduced and distributed as long as this copyright notice remains intact How old were you when your menses started? _________ Are you still having menstrual periods? Yes No Answer the following only if you are still having menstrual periods.
How many days between your periods? ____________ How many days of menstrual flow? _______________ Date of first day of last menstrual period ___________ Do you have any pain with your periods? Yes Does pain start the day flow starts? Yes Do you pass clots in menstrual flow? Yes Have you ever had an eating disorder such as anorexia or bulimia? Are you experiencing rectal bleeding or blood in your stool? Do you have increased pain with bowel movements? The following questions help to diagnose irritable bowel syndrome, a gastrointestinal condition, which may be a cause Do you have pain or discomfort that is associated with the following:
Change in appearance of stool or bowel movement? Does your pain improve after completing a bowel movement? Yes Health Habits How often do you exercise? Rarely 1-2 times weekly 3-5 times weekly Daily What is your caffeine intake (number cups per day, include coffee, tea, soft drinks, etc)? 0 1-3 4-6 >6 How many cigarettes do you smoke per day? ___________ Have you ever received treatment for substance abuse? Yes No What is your use of recreational drugs? Never used Used in the past, but not now Presently using No answer Heroin Amphetamines Marijuana Barbiturates Cocaine Other _______________________ How would you describe your diet? (check all that apply) Well balanced Vegan Vegetarian Fried food Special diet ________________________ Other __________________________ April 2008, The International Pelvic Pain Society This document may be freely reproduced and distributed as long as this copyright notice remains intact Loss of urine when coughing, sneezing, or laughing? Yes Still feeling full after urination? Yes Having to void again within minutes of voiding?
The following questions help to diagnose painful bladder syndrome, which may cause pelvic pain
Please circle the answer that best describes your bladder function and symptoms.

1. How many times do you go to the bathroom DURING
THE DAY (to void or empty your bladder)?
2. How many times do you go to the bathroom AT NIGHT (to void or empty your bladder)?
3. If you get up at night to void or empty your bladder 5. If you are sexually active, do you now or have you ever had pain or symptoms during or after sexual intercourse? 6. If you have pain with intercourse, does it make you 7. Do you have pain associated with your bladder or in your pelvis (lower abdomen, labia, vagina, urethra, perineum)? 2000 C. Lowell Parsons, MD Reprinted with permission. KCl ____ Not Indicated ____ Positive ____ Negative April 2008, The International Pelvic Pain Society This document may be freely reproduced and distributed as long as this copyright notice remains intact Coping Mechanisms Who are the people you talk to concerning your pain, or during stressful times? Mental Health provider I take care of myself How does your partner deal with your pain? Other _________________________________ Of all the problems or stresses or your life, how does your pain compare in importance? Sexual and Physical Abuse History Have you ever been the victim of emotional abuse? This can include being humiliated or insulted Yes No No answer Check an answer for both as a child and as an adult. 1a. Has anyone ever exposed the sex organs of their body to you when you did not want it? Yes No Yes No 1b. Has anyone ever threatened to have sex with you when you did not want it? 1c. Has anyone ever touched the sex organs of your body when you did not want this? Yes No Yes No 1d. Has anyone ever made you touch the sex organs of their body when you did not want this? Yes No Yes No 1e. Has anyone forced you to have sex when you did not want this? 1f. Have you had any other unwanted sexual experiences not mentioned above? If yes, please specify _________________________________________________________________________________ 2. When you were a child (13 or younger), did an older person do the following? 3. Now that you are an adult (14 or older), has any other adult done the following? Leserman, J, Drossman D, Li Z. The reliability and validity of a sexual and physical abuse history questionnaire in female patients with gastrointestinal disorders. Behavioral Medicine 1995;21:141-148. April 2008, The International Pelvic Pain Society This document may be freely reproduced and distributed as long as this copyright notice remains intact Short-Form McGill
The words below describe average pain. Place a check mark (√) in the column 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.
What does your pain feel like?
Type
None (0)
Mild (1)
Moderate (2) Severe (3)
__________ __________ __________ __________ Melzak R. The Short-form McGill Pain Questionnaire. Pain 1987;30:191-197. Pelvic Varicosity Pain Syndrome Questions Is your pelvic pain aggravated by prolonged physical activity? Does your pelvic pain improve when you lie down? Do you have pain that is deep in the vagina or pelvis during sex? Do you have pelvic throbbing or aching after sex? Yes No Do you have pelvic pain that moves from side to side? Do you have sudden episodes of severe pelvic pain that come and go? April 2008, The International Pelvic Pain Society This document may be freely reproduced and distributed as long as this copyright notice remains intact

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