Others • 3rd Park Hospital

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Do I have severe period pain, needing painkillers? Yes No

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Does my pain interfere with my daily activities during the periods? Yes No

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Do I get pain while passing stool? Yes No

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Do I get pain while passing urine, especially during periods? Yes No

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Do my pain symptoms worsen during my periods? Yes No

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Do I get pain while having sexual intercourse? Yes No

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Do I feel my period pains affect me mentally and psychologically? Yes No

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Have I tried for a pregnancy for a year or more and not succeeded? Yes No