Kardinia Health Pelvic Pain & Endometriosis Clinic - Intake Questionnaire

Important information

Please read the following information prior to completing your questionnaire to ensure this service is appropriate for you. If you are unsure or have any questions prior to completing please reach out to pelvicpainnurse@kardiniahealth.com.au or see our FAQ page https://pelvicpainclinic.kardiniahealth.com.au/clinic-faqs/

Patient criteria

This service is available to:

- females/people assigned female at birth (who have commenced menstruating i.e have had a period in the past)

- experiencing pelvic pain for more than 6 months

You do NOT require a diagnosis of endometriosis to access this service

Please note we are NOT a surgical service (i.e we do not have gynaecologists/surgeons in our team). We are a primary care team of nurses, GPs, physiotherapists, dietitians, psychologist and pain educator. We will refer to external surgical services where necessary.

I have read the above patient criteria information and believe this clinic is appropriate for me and my needs *

Fees

This is not a public service. Some appointments are subsidised by government funding but there will be some out pocket costs.

*Some subsidies are unavailable for patients without a Medicare card. Higher out-of-pocket costs will apply for these patients* If you do not have a medicare card, we suggest reaching out to the clinic nurse at pelvicpainnurse@kardiniahealth.com.au to discuss prior to paying your registration fee.

An initial registration fee of $125 ($100 for concession) is required to book your first appointment with our pelvic pain nurse. This fee is non-refundable, and not eligible for a medicare rebate/claimable on private health insurance.

This registration fee covers all nurse appointments, group education sessions and one free introductory appointment with a member of our allied health team. Your first hour long appointment with the GP (doctor) will also be bulk billed (no out of pocket costs).

All appointments beyond these may have out of pocket costs.

Cancellation fees will apply to no shows and late cancellations (this includes any 'free' appointments that are not attended)

I have read the information above and understand that a registration fee is required to book with the clinic, and some further out of pocket costs may apply *

Nurse and clinician availability

As we are a small service, we are not available every day for appointments. As at March 2025, our nurse is available on Wednesdays and Thursdays. Initial GP and allied health appointments are generally held on Thursday mornings. Group education sessions are held online in the evenings (generally Tuesdays and Thursdays)

Telehealth/video calls are available for some appointments, and attendance certificates can be provided where you need to leave work to attend an appointment. In general, you will be required to attend your first GP appointment in person in order for this particular appointment to be bulk billed.

We are NOT an urgent care service - if you have an acute pain flare or any urgent concerns please attend your regular GP or ED/urgent care centre.

I have read the information above and understand that appointments are only available on certain days/times *

If you have read and agreed to the above, please complete the rest of the intake questionnaire below in order to attend the Pelvic Pain & Endometriosis service at Kardinia Health.

Once you have completed the questionnaire you will be able to book your nurse intake appointment online. Please note you will need to pay your registration fee to secure this appointment. You can save this form and return to it later if needed. Current wait times are approximately 4-6 weeks.

We appreciate this questionnaire process is lengthy, however the more information you can provide the better informed we are of you and your symptoms. The questionnaire takes approximately 20-30 minutes to complete, and includes some sensitive questions, so we recommend you complete at a time and place when you feel safe and comfortable.

Please leave questions blank if you do not feel comfortable answering. All information is strictly confidential.

Data Collection and Privacy Statement

The Pelvic Pain and Endometriosis Clinic is supported by temporary funding from the Commonwealth Government. As part of this funding we are required to collect de-identified data about service provision and patient demographics and outcomes. It is hoped that via this data we can assess service effectiveness and lobby for ongoing funding to support continuation of the clinic.

As a Commissioned Service Provider of Western Victoria Primary Health Network (WVPHN) we are required to have appropriate controls to protect your personal information and use your personal information for authorised purposes only as per the Privacy Act 1988 (Cth), Privacy and Data Protection Act 2014 (VIC), Health Records Act 2001 and Australian Privacy Principles.

Kardinia Health will collect your information via Snapform (an online questionnaire platform), and store your information on Best Practice (Kardinia Health's clinic software). A copy of Best Practice Privacy Policy can be located here: https://bpsoftware.net/privacy-policy/ and Snapform: https://snapforms.com.au/privacy-policy/.

De-identified responses will be sent to WVPHN and the Australian Government Department of Health and Aged Care for the purpose of informing and contributing towards the evaluation of the program. It will also be used for statistical, evaluation and planning purposes at an aggregated level for the needs assessment, which is a publicly available document.

You have a right to access any personal information we hold and you may ask us to update or correct your personal information. For further information on how you can access your personal information or contact us with any questions or privacy related complaints, please visit our Privacy Statement https://kardiniahealth.com.au/privacy-policy-2/ or contact us at (03) 5202 9333

Please also see WVPHN Privacy Statement https://westvicphn.com.au/privacy-statement/

You can withdraw consent for deidentified data sharing at any time by contacting our Pelvic Pain nurse on (03) 5202 9333 or emailing pelvicpainnurse@kardiniahealth.com.au

First Name *

Last Name *

I consent to my data collection and sharing of my de-identified data as outlined above *

YesNo

Please note - if you choose not to consent you will still be seen at the clinic, and the following information will be collected by Kardinia Health for the purpose of clinical service provision only and will not be shared with WVPHN

The Kardinia Health Pelvic Pain and Endometriosis Service is a pilot program, and future research may be conducted into service provision and outcomes (separate to the data collected by WVPHN). Do you consent to the following:

Kardinia Health contacting and inviting you to be part of a research study?

YesNo

Your de-identified medical data being used for research purposes within Kardinia Health?

YesNo

Your de-identified medical data being used for ethically approved research purposes with external research organisations, for example Deakin University, Barwon Health

YesNo

Patient details

Date of birth *

Contact phone number *

Email *

What was your assigned sex at birth? *

FemaleMaleIntersex

What are your pronouns?

She/herHe/himThey/themOther

Are you of Aboriginal and/or Torres Strait Islander origin? *

Do you have another ethnicity/cultural background you would like to note?

Do you have a regular GP? If so please list their details below

Do you have a GP chronic disease management plan in place? If so, when was this last completed/reviewed?

Do you have a GP mental health care plan in place? If so, when was this last completed/reviewed?

Medical and Social History

Have you previously been diagnosed with endometriosis? *

Yes - diagnosed with surgery (laparoscopy)Yes - diagnosed based on ultrasound findingsYes - diagnosed by a doctor/healthcare professional based on other findingsNoUnsure

Have you been diagnosed with any medical conditions (including mental health conditions)? Please list details below:

Have you ever had any surgeries? If so please list details and approximate year below:

Do you have any allergies? If so, please list details below:

Do you take any medications (including over the counter and herbal remedies/supplements? Please list details below:

Medication name

Dose and frequency

Timing

When taken

Have you had a Cervical Screening test (aka Pap smear)? If so, please list previous year and result if known:

Have you had any previous pregnancies? If so, please list approximate year and outcome (eg miscarriage, termination, vaginal delivery, Caesarean section)

If previously pregnant, were there any problems/difficulties during your pregnancy, delivery or postpartum?

Do you have any family history of note? Eg breast/ovarian cancer, bowel cancer, endometriosis

Are you currently employed? If so, what is your job/role?

Do you smoke?

Yes No Ex-smokerSocial smoker

If yes, how many cigarettes per day do you smoke on average? (leave blank if you are not currently smoking)

On average, how many standard drinks of alcohol would you consume in one week?

Do you use recreational/illicit drugs? eg marijuana, cocaine

YesNoIn the past but not currentlyPrefer not to say

What types of exercise/physical activity do you enjoy?

How many hours sleep do you get per night on average?

Do you have any particular dietary requirements/modifications (eg Coeliac, vegetarian, low FODMAP)? Please list details below:

How would you rate the quality of your diet currently?

ExcellentGood AveragePoor

What do you do to relax?

Menstrual and Sexual history

Approximately how old were you when you had your first period?

For the following 3 questions, please consider a typical period (i.e when you are not using hormonal medications eg the pill, mirena, implanon). If you have not had any breaks from hormonal medications/devices please leave blank.

How often do you get a period?

How long does your period usually last?

How many times a day do you change a pad/tampon/menstrual cup during the heaviest days of your period?

Do you have any bleeding between periods?

YesNoUnsure

Do you have any bleeding after sexual activity?

YesNo UnsureNot sexually active

Are you currently utilising contraception/birth control? If so, please list what type (eg condoms, contraceptive pill, IUD)

Have you previously been diagnosed with a sexually transmitted infection? Please list details if known:

When was your last sexually transmitted infection (STI) screen? (If not sexually active, please write N/A)

Have you had any new sexual partners since your last STI screen?

Yes No UnsureN/A

Other:

Pelvic pain/symptom history

Please write any details you would like to include here:

Please circle or mark the areas where you have felt persistent or recurrent pain in the last 3 months

Clear drawing

Use your mouse or finger to mark/circle the location of your pain, to the best of your ability.

Please circle or mark the areas on the vulva/groin where you have felt persistent or recurrent pain in the last 3 months (leave blank if no pain)

Clear drawing

Use your mouse or finger to mark/circle the location of your pain, to the best of your ability.

Continuing on from the diagram above, please list the areas you have felt persistent or recurrent pain below (please start with the most significant to you) and fill in the additional details to the best of your ability

Location of pain

How long have you had this pain?

How many days per month do you have this pain?

What is the timing of this pain?

Severity of pain (1-10)

What investigations have you had for your pain? Please include approximate date and where you had these done (if known)

Do you have any of the following urinary problems (tick all that apply):

If sexually active, do you experience any of the following (tick all that apply):

Are you trying to become pregnant or have plans in the near future?

Do you have any other symptoms not listed above?

How do your symptoms impact on your daily life?

During the last month, how many days did you miss from work or school because of your symptoms? (includes days you went in late or left early because of your symptoms. If no days were missed please write 0. If you are not working or at school at present write NA) *

Which treatments did you find helpful?

What healthcare providers have you seen (both in the past and now) for this pain? (eg GPs, gynaecologists, physiotherapist, psychologists, acupuncturists). Please list all providers and what treatments were undertaken (including any surgeries)

Healthcare professional

Treatment provided

When seen and for how long?

Was there any benefit and for how long?

Have you attended the Emergency Department in the past for your symptoms/pain? *

YesNoUnsure

If yes, how many times in the last 6 months? (If no, please write 0) *

What do you expect/hope for in attending this clinic?

What worries you about your pain?

The Pelvic Pain Impact Questionnaire (PPIQ)

Thank you for completing your questionnaire. PLEASE COMPLETE THE BOOKING AND REGISTRATION BELOW IN ORDER TO SUBMIT THE FORM TO OUR TEAM.

If you have any concerns/questions please email pelvicpainnurse@kardiniahealth.com.au. You can save this form and come back to it later.

Book your nurse intake appointment now *

Select a Service

Would you like to be contacted if an earlier appointment becomes available? *

Please note: If you require telehealth, please email pelvicpainnurse@kardiniahealth.com.au at least one week prior to your appointment in order to receive a video link.

Please pay your intake fee below and submit the form in order to secure this appointment

Select

Amount including processing fee:

Health care card/concession card number (if applicable)

Patient billing information *

Thank you for completing this survey. Is there anything else you would like to add?

Save and Complete Later