Endometriosis Health Assessment
Please complete this assessment to help evaluate your symptoms and experiences related to endometriosis. Your responses will assist your healthcare provider in understanding your condition.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Have you been diagnosed with endometriosis by a healthcare professional?
*
Yes
No
Not sure
Please indicate the severity of the following symptoms over the past 3 months.
*
Rows
None
Mild
Moderate
Severe
Pelvic pain
1
2
3
4
Painful periods
5
6
7
8
Pain during intercourse
9
10
11
12
Pain with bowel movements
13
14
15
16
Pain with urination
17
18
19
20
Chronic fatigue
21
22
23
24
How would you rate the impact of your symptoms on your daily life?
*
1
2
3
4
5
6
7
8
9
10
Have you previously received any treatment for endometriosis?
*
Yes, medication
Yes, surgery
No treatment received
Other
Do you have a family history of endometriosis (mother, sister, aunt, etc.)?
Yes
No
Not sure
How long have you been experiencing symptoms?
*
Please Select
Less than 6 months
6-12 months
1-3 years
More than 3 years
Are you currently taking any medications for your symptoms?
Yes
No
Please describe any additional symptoms or concerns you would like to mention.
Submit Assessment
Should be Empty: