Pain Questionnaire

Patient Information

First Name *

Last Name *

Age: *

Current specialists and contact details:

If you are currently seeing a psychologist, psychiatrist, or physiotherapist please provide contact details below:

Are you currently:

Employed full timeEmployed part timeUnemployed

If unemployed:

Looking for workOff work due to ill-health (not chronic pain)Off work due to chronic pain

Information on your pain symptoms / condition

Please provide as much information as possible on the following questions

How did your pain start?

How has your pain changed since you first noticed it?

What remedies/treatments/surgeries/medications have you tried? Please comment on their effectiveness.

Which statement best describes your pain? (Tick one box only) *

Always present (always the same intensity)Always present (level of pain varies)Often present (pain free periods last less than 6 hours)Occasionally present (pain occurs once to several times per day, lasting up to an hour)Rarely present (pain occurs every few days or weeks)

Health care (other than your visits to the pain clinic)

1. How many times in the past 3 months have you seen a general practitioner in regard to your pain? *

2. How many times in the past 3 months have you seen a medical specialist (e.g. orthopaedic surgeon) in regard to your pain? *

3. How many times in the past 3 months have you seen health professionals other than doctors (e.g. physiotherapist, chiropractor, psychologist) in regard to your pain? *

4. How many times in the past 3 months have you visited a hospital emergency department in regard to your pain? (include all visits, regardless of whether or not you were admitted to the hospital from the emergency department) *

5. How many times in the past 3 months have you been admitted to hospital as an inpatient because of your pain? *

6. How many diagnostic tests (e.g. X-rays, scans) have you had in the last 3 months relating to your pain? *

Does the pain have one or more of the following characteristics?

1 - Burning

YesNo

2 - Painful cold

YesNo

3 - Electric shocks

YesNo

In the pain associated with one or more of the following symptoms in the same area?

4 - Tingling

YesNo

5 - Pins & needles

YesNo

6 - Numbness

YesNo

7 - Itching

YesNo

What other medical problems do you have? (e.g. asthma, diabetes, previous surgeries)

Do you have any allergies?

Do you take any medications that thin the blood?

Do you smoke? *

YesNo

If 'yes', how many cigarettes per day?

Do you drink alcohol? *

YesNo

If 'yes', how much do you drink per week?

Medication use

Are you taking any medications? *

NoYes

Please use the space below to list ALL the medications you are taking, including both prescription and over-the-counter medicines. Alternatively, please attend your appointment with a complete & up to date list of your current medications & prescriptions.