Nova Health Co Endometriosis & Pelvic Pain Clinic - Intake Questionnaire

Important Information

Save and Complete Later

Please read the following information prior to completing your questionnaire to ensure this service is appropriate for you.

Our intake form takes approximately 40 minutes to complete. While extensive, it allows us to provide holistic care tailored for endometriosis and persistent pelvic pain.

Please note an out-of-pocket fee of $100 is required to schedule an appointment following completion of this form.

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 and pain educators. 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

After submitting the form, you will receive a link to book your first appointment with our clinic nurse. An out-of-pocket fee of $100 is required to schedule this appointment.

If you are experiencing financial hardship, please email eppcadmin@novahealthco.com.au to request consideration for a fee waiver.

This registration fee covers all appointments and group education sessions.

Late-cancellation (within 24 hours of your appointment) and non-attendance will result in withdrawal from the program.

I have read the information above and understand that a registration fee is required to book with the clinic *

Nurse and clinician availability

As we are a small service, availability is limited and will be capped to ensure we can effectively provide continuity of care to our patient cohort. We will triage intake and keep patients updated on wait-times regularly. Our clinic will run across four days per week.

Telehealth/video calls are available for some appointments, and attendance certificates can be provided where you need to leave work to attend an appointment. You will be required to attend your initial nurse appointment and initial GP appointment in person.

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

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 Endometriosis and Pelvic Pain Clinic at Nova Health Co.

Please complete every question. If a question does not apply to you, write N/A. You can save this form and return to it later if needed.

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 Murrumbidgee Primary Health Network (MPHN) 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 and Personal Information Protection Act 1998 No 133 - NSW Legislation.

Nova Health Co will collect your information via Snapform (an online questionnaire platform), and store your information on Best Practice (Nova Health Co'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 MPHN 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://novahealthco.com.au/wp-content/uploads/2024/03/Practice-Information-Sheet.pdf or contact us at (02) 6921 2040.

Please also see MPHN Privacy Statement https://mphn.org.au/disclaimer-privacy-statement

You can withdraw consent for deidentified data sharing at any time by contacting us on (02) 6921 2040 or emailing eppcadmin@novahealthco.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 Nova Health Co for the purpose of clinical service provision only and will not be shared with MPHN.

The Nova Health Co Endometriosis and Pelvic Pain is a pilot program, and future research may be conducted into service provision and outcomes (separate to the data collected by MPHN and the Department of Health and Ageing). Do you consent to the following:

Nova Health Co contacting and inviting you to be part of a research study? *

YesNo

Your de-identified medical data being used for research purposes within Nova Health Co? *

YesNo

What is your presenting concern? *

EndometriosisPelvic PainMenopause

Patient Details

Date of Birth: *

Contact phone number *

Email *

What was your assigned sex at birth? *

MaleFemaleIntersex

What are your pronouns? *

She/herHe/himThey/themOther

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

Do you identify as part of the LGBTQI+ community? *

YesNoPrefer not to say

Do you identify as a person with a disability? *

YesNoPrefer not to say

Do you identify as coming from a culturally and linguistically diverse background? *

YesNoPrefer not to say

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? *

YesNoEx-smokerSocial smoker

If yes, how many cigarettes per day do you smoke on average? *

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 write N/A.

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

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

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) *

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 N/A) *

Rank from 0 (no impact on study/work) to 10 (completely prevented me from working/studying)

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? *

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)

Is there anything else you would like to add?

Thank you for completing this questionnaire.

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