Kardinia Health Pelvic Pain & Endometriosis Clinic - Intake Questionnaire (Teens Version)

Important information

This teen service is a modified version of our Pelvic Pain and Endometriosis Service. It provides bulk-billed (free) appointments with a GP to assess your needs and get you started with a management program, without the need to utilise our full pelvic pain program or pay the associated registration fee. This service does not include any free allied health services, but we can refer you on to these services if they may benefit.

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

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

- under the age of 18 at time of intake (if you are over 18 please see our other intake form). You are able to bring a support person but can also attend on your own

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).

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, but appointments are subsidised by federal funding. You can access up to 5 bulk billed services with our pelvic health GP (this means no out of pocket cost). You also have access to our pelvic pain nurse for additional support (free of charge)

Appointments beyond this may involve an out of pocket fee.

Any appointments with allied health specialists or referred specialists may also involve a fee.

Procedures (such as implanon insertions, IUD insertions, iron infusions) may involve an out of pocket fee to cover equipment costs

I have read and understand the information above *

Clinician availability

As we are a small service, we are not available every day for appointments. As at December 2025, teen appointments will be held on Thursday and Saturday mornings.

If you need support outside this time, our nurse is available Mondays and Thursdays - please contact via email on pelvicpainnurse@kardiniahealth.com.au

Telehealth/video calls are available for some appointments, and attendance certificates can be provided where you need to leave school/work to attend an appointment.

Please note 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 (Teen service).

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 data about our clinic services and patients (this is all de-identified - meaning your name is not collected).

This data is collected by Western Victoria Primary Health Network (WVPHN). Both Kardinia Health and WVPHN have appropriate controls to protect your information, and will 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 evaluation of our program and to help inform ongoing needs.

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

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:

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

Do you smoke or vape?

Yes No Ex-smokerSocial smoker

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

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?

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:

Other:

Pelvic pain/symptom history

Please write any details you would like to include here:

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

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) *

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?

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 GP 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.

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

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