Second Opinion

If you suspect that you suffer from endometriosis, please consult your primary Ob/Gyn. After a thorough examination, you should receive a full explanation and a range of options. If this does not occur, or you are unhappy with the provided options, seek a second opinion. To receive a second opinion from a specialist at the Endometriosis Institute, please complete the Endometrisois Institute form below.

After reviewing the information you provide, we will send you a questionnaire which will also need to be completed. You will need to then forward the completed questionnaire along with the copy of your medical records including copies of all surgical and pathology reports and tests to our office. All of this information will be reviewed and you will receive a written report which you can share with your primary OB/Gyn.

First Name:
Last Name:
Address 1:
Address 2:
City:
If live in USA, what State:
Zipcode:
Country:
E-Mail Address:
Re-type E-Mail Address:
Phone:
Your Age:
Your Height:
Your Weight:
Why are you seeking Second Opinion:
Specify any current treatment:
Who have you seen:
Results to date:
# years trying to get pregnant:
# children:
# miscarriages:
How old were you when you first menstruated:
# days usually between periods:
How long do periods last:
Any mid-cycle bleeding:
Date of last menstrual cycle:
Menstrual period pain level:
Do you have regular menstrual cycles:
Heavy or light menstrual flow:
Is Pap Smear within normal limits:
Is mammogram within normal limits:
Describe any family genetic abnormalities:
If appropriate, why were you excluded from donating blood:
Describe any surgeries:
Describe Alcohol and Drug usage:
Any dietary restrictions:
Any allergies:

Have you ever been told in the
past, that you have had any of the
following? (check all that apply):		 Abnormal Pap Smear
Hepatitis A, B, or C
Acne
Herpes
AIDS
High blood pressure
Allergies
Hypertension
Anemia
Intolerance to hot/cold
Alzheimer's Disease
Jaundice
Anorexia
Kidney Disease
Appendicitis
Loss of libido
Arthritis
Loss of scalp hair
Autoimmune Disorder
Measles
Colitis
Multiple Sclerosis
Blocked fallopian tubes
Neurologic problems
Breast Cancer
Nongonococcal Urethritis
Breast masses
Ovarian Cancer
Breast secretions
Ovarian cysts
Bronchitis
Pain with intercourse
Cancer
Parasitic infections
Cervical Cancer
Pelvic Inflammatory Disease (PID)
Chlamydia
Pneumonia
Chronic cough
Polycystic Ovarian Syndrome (PCOS)
Chronic Pelvic Pain (CPP)
Poor sense of smell
Condyloma
Psychiatric care
Diabetes
Rheumatic Fever
Endocrine Disease
Scarlet Fever
Endometriosis
Seizures
Gonorrhea
Sexually Transmitted Disease (STD)
Epilepsy
Syphilis
Excessive hair growth
Thyroid problems
Excessive sweating
Transfusion problems
Excessive weight change
Tuberculosis
Fibroids
Ulcers
Dizziness
Ureaplasma/Mycoplasma
Frequent headaches
Vaginitis
Gallbladder Disease
Visual disturbances
Heart Disease
Depression
Schizophrenia
Obsessive-Compulsive Disorder
Self-mutilation

Any issues we should be aware:

 

 

Specific question you want addressed:

 

 
Are You:
 

 

 

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