Pain Abdomen Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Name *FirstLastEmail * Do you have generalized abdominal discomfort or pain (pain that is difficult to pinpoint)?Never / don't knowOccasional moderate discomfort Frequent moderate discomfort Occasional severe pain Frequent severe pain Do you have pain at the right side of your abdomen, between the bottom rib and the hip? Never / don't knowOccasional moderate discomfort Frequent moderate discomfort Occasional severe pain Frequent severe pain Do you have pain at the left side of your abdomen, between the bottom rib and the hip? Never / don't knowOccasional moderate discomfort Frequent moderate discomfort Occasional severe pain Frequent severe pain Do you have pain at the lower front of your abdomen? Never / don't knowOccasional moderate discomfort Frequent moderate discomfort Occasional severe pain Frequent severe pain Do you have a dull, constant ache on either or both sides of your lower abdomen near the pelvis, but above the genital area? Don't knowNoLeft side only Right side onlyBoth sides or in the middleAre you currently experiencing severe pain in the lower abdomen?Don't knowNoYes, lower left side only Yes, lower right side onlyYes, both sides and middle If you are currently experiencing abdominal pain, for how long has this pain been present?Not applicable / don't knowLess than one week1-4 weeks 1-3 monthsOver 3 months When you have abdominal pain, does a bowel movement reduce it? Not applicable / don't know No Moderate improvement Big improvement - the pain disappears Does a large or fatty meal cause upper abdominal pain, perhaps worse at night?No / don't know In the past onlyMildly / occasionallyModerately / often Seriously / always Have you suffered from heartburn (burning at top of stomach) or gastric reflux? Don't know NoPast episode(s) now resolvedCurrent minor problemCurrent major problemDo you have a sense of lower abdominal fullness, NOT caused by abdominal gas? Don't know NoSomewhatDefinitely, but not all the timeDefinitely, almost always Are you experiencing any abdominal swelling or bloating? Don't know NoYes, slightly noticeable Yes, very noticeable Add any additional information here for the questions above: Have you noticed pressure or 'fullness' under your lower left rib cage, which is painless or slightly tender? Do not answer this question if there is definite pain in this area. Don't know / there is definite pain NoYes, slight pressureYes, definite pressureDo you have pain or discomfort in the upper abdominal (stomach) area, below the breastbone?Don't knowNoOccasionally / mildSeveral times a week / moderate Frequently / severe MessageSubmit