PIP Assistance Request

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Welcome To Hey Endo!
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PIP Assistance Request

Name

Mobile Number

Are you a member of our facebook support group?

Yes No

Select the conditions that apply to you:

Endometriosis Suspected Endometriosis Adenomyosis Suspected Adenomyosis PMOS (formally known as PCOS) Suspected PMOS Other gynaecological condition Suspected other gynaecological condition

Please give details of your diagnosis dates. Leave this blank if you have not yet been diagnosed.

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 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

Welcome To Hey Endo!
About Us
Research
Archive
Resources
Get Help

Welcome To Hey Endo!
About Us
Research
Archive
Resources
Get Help