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0330 058 1850
Pelvic Congestion Screening Test
Pelvic Congestion Syndrome Screening
1
Personal Details
2
Symptoms
3
Signs
Name
*
First
Last
Email
*
Enter Email
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Where did you hear about us?
*
Where did you hear about us?
GP/Consultant
Magazine / Newspaper
The Whiteley Clinic Newsletter
Social Media
Google
Radio
Recommendation from friends/family
Other (Please state below)
Other
Date of birth
*
Gender
*
Female
Male
Do you live in the United Kingdom?
No
Yes
What region of the UK do you live in?
*
South East
London
North West
East of England
West Midlands
South West
Yorkshire and the Humber
East Midlands
North East
Scotland
Wales
Northern Ireland
Would you like to receive marketing material from The Whiteley Clinic?
Would you like to receive marketing material from The Whiteley Clinic?
YES
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Symptoms
Do you suffer from any of the following:
Aching or "dragging" feeling in the pelvis on standing or sitting?
If so are...
your symptoms worse at the end of the day?
your symptoms worse before the onset of menstruation?
your symptoms eased when you Iie down?
Irritable bladder
Irritable bowel
Deep pain or discomfort during sexual intercourse
Deep pain or discomfort after sexual intercourse?
Backache
Abnormal bleeding during menstruation
Depression or feeling low because of your symptoms
Vaginal discharge
Tender lower abdomen
Signs
Do you suffer from any of the following:
Swelling of the vagina or vulva
Varicose veins of the vulva or vagina
Varicose veins around your buttocks or very top of inner thighs
Haemorrhoids
Have you had children?
Yes
No
Have you had at least one child by normal delivery?
Yes
No
Does pelvic congestion sydrome run in your family?
Yes
No
Don't know
Do leg varicose veins run in your family?
Yes
No
Don't know
0330 058 1850
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