Which Information is required for an Endometriosis Consultation ?
Information necessary for the first visit : please fill in to be complete
After download : open, save or print
After download : open, save or print
( Download the formula “Information for the endometriosis outpatient visit” ; the best is to fill in beforehand.
Pain
| Since when?: | …………………….. | months/years |
| Type of Pain : | during periods : …/3 ; every day : …/3 ; pain at intercourse : …/3 | scoring : |
| pain to go to the toilet : …/3 ; pain during miction : …/3.during periods | from 1 to 3 | |
| Where Pain ? | lower back ? hypogastric ? |
circle |
| Radiation to | lower back, anterior side of the legs up to the knee, the whole leg le/ri , perineal (anus and vagina) | circle |
Infertility
| Since when?: | …………………….. | months/years |
| Exploration | ovulation | complete |
| transport | ||
| implantation | ||
| cervical function | ||
| spermiogram | ||
| IVF | number : ….. ; where ? Result ? |
Investigations
| Ultrasound | …………………….. | when ? by whom ? results ? |
| Laparoscopy | ………………………… | |
| IVP | ||
| Contrast Enema | ||
| Others | MRI CATscan |
Other surgery for Endometriosis ?
Complete : where ? by whom ? Laparoscopy?, laparotomy ? ; bowel resection ? Complete ?
Medical therapy .
before and after surgery