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PIP Assistance Request Form
Hull & East Yorkshire Endometriosis Support
A Registered Charity 1208886
Welcome To Hey Endo!
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Welcome To Hey Endo!
About Us
Research
Archive
Resources
Get Help
Period Product Request Form
HEY Endo Referral Form
PIP Assistance Request Form
Contact Us
PIP Assistance Request Form
First Name
Last Name
Email
Are you a member of our facebook support group?
Yes
No
Select the conditions that apply to you:
Endometriosis
Suspected Endometriosis
Adenomyosis
Suspected Adenomyosis
PCOS
Suspected PCOS
Other gynaecological condition
Suspected other gynaecological condition
When were you diagnosed with Endometriosis? Leave this blank if you have not yet been diagnosed or do not have this condition.
When were you diagnosed with Adenomyosis? Leave this blank if you have not yet been diagnosed or do not have this condition.
When were you diagnosed with PCOS? Leave this blank if you have not yet been diagnosed or do not have this condition.
Select the symptoms that you're experiencing:
pelvic pain
leg pain
blood in urine
heavy bleeding
pain when opening bowels
irregular bleeding
pain when passing urine
bloating
pain during/after sex
blood in stool
back pain
fatigue
dizziness
iron deficiency
nausea
infertility
hirsutism (excessive hair growth)
acne
Please list any other symptoms here...
Are you taking or using any of the following medications or therapies?
zoladex
prostap
HRT
the combined pill
progesterone only pill
dienogest
depo injection
mirena coil
copper coil
nexplanon
contraceptive patch
paracetamol
ibuprofen
co-codamol
naproxen
codeine
tramadol
morphine
TENS machine
BeYou patches
heat pad
hot water bottle
ice pack
CBD
muscle rub
acupuncture
cupping
massage
physiotherapy
none
Are you currently waiting for surgery?
Yes
No
I am waiting to see a consultant and hoping to be added to the surgery list
I have been told I cannot have more surgery
Please select the activities you struggle with due to your symptoms
making food or cooking
feeding yourself
managing therapies/medications
washing and bathing
urinary incontinence
bowel incontinence
getting on and off the toilet without help
dressing and undressing
communicating verbally with others
reading and understanding things
socialising
handling your finances
planning and following a journey
walking so regular breaks are taken
walking so a walking stick is used
walking so a wheelchair is used
none
Send
Welcome To Hey Endo!
About Us
Research
Archive
Resources
Get Help
Period Product Request Form
HEY Endo Referral Form
PIP Assistance Request Form
Contact Us
Welcome To Hey Endo!
About Us
Research
Archive
Resources
Get Help
Period Product Request Form
HEY Endo Referral Form
PIP Assistance Request Form
Contact Us
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