📋 Pre-consultation Questionnaire: Pelvic Congestion

Pelvic varices: Pelvic Congestion Syndrome (PCS)

Why complete this questionnaire?
This questionnaire helps us prepare your consultation and assess the intensity of your symptoms. It can be sent to our team through the contact form and will be available at your appointment. It does not replace a medical consultation.

👤 Personal information

🩺 Your history

📊 Pain score: Pelvic Congestion Syndrome

These questions assess the intensity of your pelvic congestion syndrome. Please answer as accurately as possible.

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No painWorst pain
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No impactMajor impact

💬 Additional information

📄 This questionnaire is meant to be completed at home, ahead of your consultation. Fill it in, then print it or save it as a PDF and bring it with you on the day of your appointment. Nothing is sent automatically. If you would like to send it in advance, you can email it yourself via Contact us (at your own responsibility).

Your answers are intended for Pr Dohan · IR Cochin and are used only to prepare your consultation.