Pain And Symptom Diary Template Page 2
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33.
4.
Do you get pain during or after intercourse?
5.
Does anything (walking, exercise, stress etc) make this pain worse?
6.
How would you describe the pain? (Please circle all that apply)
Stabbing
Spasm
Burning
Dull
Aching
Sharp
Constant
Throbbing
Random
Agonising
Shooting
Cramping
Symptoms
1.
Do you have pain or bleed when you have a bowel movement? Y/N
If so, is this worse during your period?
2.
Do you have pain or bleed when you urinate? Y/N
If so, is this worse during your period?
3.
Do you feel bloated? Y/N
If so, is this worse during your period?
4.
Are you physically tired? Y/N
If so, do you get more tired during your period?
5.
Do you feel sick, vomit or faint during your period?
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Parent category: Life