This questionnaire is made for you to get a better picture of your pain. Share your answers with your general practitioner and together you can find an explanation for your symptoms.
Please use the numbers 0-5 to mark your answers to each question relevant to you.
0 = Not at all || 1 = Barely || 2 = Somewhat || 3 = Moderately || 4 = Strongly || 5 = Unendurably
In a few cases, you might need to underline words or write a remark.
- How annoying has your pain been during the past week?
- Is your pain located in a specific place?
- Is it in the vulva
- More specifically: Is it located at the entrance to the vagina, urethra, clitoris, labia, or at the perineum towards rectum?
- In your vagina
- Is it on the inside or at the entrance?
- Is it inside the vagina towards your bladder or opposite?
- Is it deep on the inside of the vagina?
- Is it in the top, superficial surface of your vaginal tissues?
- Is your pain located more in-depth in the vaginal tissue?
- Do you have other pain concerns or issues in your pelvic area?
- Do you experience pain elsewhere in the body?
- Joint pain in the pelvis?
- Lower back pain?
- Abdominal pain?
- Pain in the groin?
- Buttock pain?
- Leg pain?
- Is it in the vulva
- Do you experience pain when lifting?
- Do you experience pain when sitting?
- Do you experience pain when walking?
- Do you experience pain during other physical activity?
- Do you experience pain when wearing tight clothes (pants, underpants)?
- Do you experience pain during sexual activity?
- Do you experience dryness right at the entrance of the vagina during sex?
- Do you find that your skin cracks or tears due to penetration?
- Does your pain occur when penetrated (tampon use, by gynaecological examination, insertion of fingers, a penis, toys)?
- Do you find that it feels like there is a wall at the start of the vagina?
- Do you find that there are spots in the vagina which are very painful?
- Does your pain occur during deep penetration?
- Does your pain show up after some time of penetration?
- Do you experience vaginal dryness during sex?
- Has intercourse always been painful?
- Do you experience fear that penetration will hurt?
- Do you have difficulty getting aroused sexually?
- Do you have difficulty reaching orgasm?
- Do you experience pelvic pain hours or days after sexual intercourse?
- Do you experience itching in everyday life?
- Do you experience swelling?
- Do you have rashes/redness?
- Do you have sores, warts, or blisters?
- Is your skin fragile?
- Is your skin very thick or hard (e.g. scar tissue)?
- Have you experienced different/foul-smelling vaginal discharge?
- Have you experienced changes in skin/tissue colour?
- Do you experience thick, white, lumpy discharge?
- Do you experience pain:
- At ovulation (mid-cycle)?
- Just before menstruation?
- Intense pain during menstruation?
- After the end of menstruation?
Do you experience pain when:
- The bladder is full
- After having urinated
- The intestine is full
- After defecation
Do you experience:
- You drip a little urine when coughing, sneezing, lifting, or laughing
- Sudden urge to urinate
- Difficulty starting to pee
- Difficulty emptying the bladder
- Difficulty emptying the bladder without pushing
- The need to get up at night to urinate
- Frequent urinary tract infections (more than 1-2 times per year)
- Urinating more than average (more than once every 2 hours)?
- Are you bothered by constipation (less than three bowel movements per week)?
- Are you bothered by frequent bowel movements (more than three times per day)?
- Do you find that you can not get rid of all your stool at once?
- Do you experience sudden bowel movements?
- Do you feel bloated?
- Do you experience lumpy or hard stools?
- Do you experience loose or watery stools?
Effect on daily life:
Select the inconvenience that bothers you most in daily life, such as itching, pain, dryness, etc.
How much do you estimate that the selected complication affects your daily life negatively concerning:
- Exercise habits?
- Activities like lifting, cleaning, sitting etc.?
- Your sex life?
- Mood changes?
Do you take steps to alleviate your discomfort:
- Apply cold?
- Apply heat?
- Get up and walking around?
- Meditation, breathing exercises, relaxation techniques?
- Creams or gels?
- Pain medication?
- other _____________
Are you using any medicines?
- IUD (copper or hormonal)
- Hormonal implants
- Have you given birth vaginally?
- Have you had surgery in the pelvic area (biopsy, during/after birth, abortion, cyst/fibroid removal, other pelvic surgery)?
- Has your mother had pelvic problems?
What words describe your nuisances:
|incapacitating||to cry over||severe||constant||sudden|