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Patient Questionnaire For Pelvis Exam

Patient Name

D.O.B.

Date of Exam

Please describe your symptoms

Do you have or have you had, any of the following?

Pelvic Pain

Yes No

Missed / Irregular Menstrual Cycles

Yes No

Very Painful Periods

Yes No

Infertility

Yes No

Endometriosis

Yes No

Radiation Therapy in the Pelvis

Yes No

Fibroid

Yes No

Endometrial Cancer

Yes No

Do you have a history of any of the following?

Endometrial Cancer

Yes No

Cervical Cancer

Yes No

Ovarian Cancer

Yes No

Have you had surgery of?

Right Ovary

Yes No

Date:

Details:

Left Ovary

Yes No

Date:

Details:

Uterus (Including a Caesarian Section or Hysterectomy)

Yes No

Date:

Details:

Cervix

Yes No

Date:

Details:

Fallopian Tube

Yes No

Date:

Details:

Other Pelvic

Yes No

Date:

Details:

Endometrial Sampling or Hysteroscopy

Yes No

Date:

Details:

Uterine Artery Embolization

Yes No

Date:

Details:

Are you on Hormone Replacement Therapy?

Yes No

Do you have an IUD?

Yes No

Have you had any of the following exams?

Ultrasound

Yes No

Date:

Details:

Hysterosalpingogram or sonohysterogram

Yes No

Date:

Details:

Cat Scan

Yes No

Date:

Details:

MRI

Yes No

Date:

Details: