Information for a first visit
Pain
| Since when?: | .and how did it started ……………………. | months/years |
| Type of Pain : | during periods : …/3 ; every day : …/3 ; pain at intercourse : …/3 | scoring : |
| pain when going go to the toilet : …/3 ; pain during micturition : …/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 le/ri, 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 ? |
Previous investigations
| Ultrasound | …………………….. | when ? by whom ? results ? |
| Laparoscopy | ………………………… | |
| IVP | ||
| Contrast Enema | ||
| Others | MRI CAT scan |
Surgery ?
where ? by whom ? Laparoscopy ?, laparotomy ? ; bowel resection ? Complete ?
Medical treatment ?
which treatment, before and after surgery
Bring all reports you have
pain radiation
only backpain is not endo
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