Parent Pain Questionnaire Understanding your child s pain
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1 Parent Pain Questionnaire Understanding your child s pain This questionnaire is to help us learn about your child's pain problems. All information obtained from this questionnaire and in interviews will remain private. If you do not wish to answer a question, write, "do not wish to answer" in the space provided. Please print or write clearly. Today's date: Your name: Your relationship to the child: Child s name: Date of birth: Grade in school: List the name, relationship, age and gender of everyone living in the home. Name Relationship Age Gender What do you call your child's pains? (For example, "headache," "joint pain," "stomachache," "backache," etc.) List them in order of severity, #1 being the most severe pain. Pain Problem #1: Pain Problem #2: Pain Problem #3: 1
2 Mark an X on the exact place where you think your child is having pain now. If there is more than one painful place, mark them 1, 2, 3, etc. Start with the most painful place as 1. Front Back Right side of head Left side of head 2
3 When did your child's present pain problem begin? Explain the symptoms and exact locations of pain. My child s pain: is always there comes and goes is always there but sometimes gets worse My child s pain is: staying the same getting worse getting better Mark the words below that best describe your child s pain, or the way your child feels when hurt or in pain. cutting pounding tingling tiring deep squeezing throbbing horrible stabbing burning pulling sickening biting screaming scraping aching uncomfortable cold miserable stretching pricking hot scared lonely jumping pinching unbearable sad itching grabbing stinging sharp sore flashing pins and needles Other: (describe) Rate how much pain you think your child is having at the present time by placing a mark somewhere on the line. Not hurting Hurting a whole lot No discomfort Very uncomfortable No pain Severe pain Rate how much pain you think your child has on an average each day by placing a mark somewhere on the line. Not hurting Hurting a whole lot No discomfort Very uncomfortable No pain Severe pain Rate how severe the worst pain your child had in the past week (7 days) by placing a mark somewhere on the line. Not hurting Hurting a whole lot No discomfort Very uncomfortable No pain Severe pain 3
4 How many hours a day does your child have pain now? How long does a single pain episode last (minutes, hours)? What time of the day does your child have the most pain? What day of the week does your child have the most pain? What week of the month does your child have the most pain? What season or month does your child have the most pain? Is your child's pain worse when they are: (please mark all that apply) tired angry upset anxious busy unhappy bored lonely arguing happy Other: (describe) Does your child have any other symptoms with the pain? (please mark all that apply) stiffness swelling redness heat anxiety nausea vomiting dizziness fainting fast breathing fast heart rate sweating Other: (describe) Is your child currently taking any medicine for pain? Yes No If yes, complete the following information, indicating how effective. Medication Dose How often How Effective 0 = not effective 10 = very effective 4
5 List any other medications you have tried in the past for your child s pain. Medication Dose How often How Effective 0 = not effective 10 = very effective List any other medications your child is currently taking. Medication Dose How often Reason What do you currently do, besides giving medicine, to relieve your child's pain? Does your child s pain interfere with any of these activities? Circle the number that best describes how often. Never Rarely Sometimes Often Always Enjoying the family Eating/appetite Sleeping Seeing friends Watching T.V Schoolwork Attending school Favorite activities Other activities Comments? 5
6 During the past three months of the school year, how often did your child s pain keep them from going to school? Never 4-7 days more than 3 weeks 1 day only more than 1 week more than 1 month 2-3 days more than 2 weeks During the past three months, how often did your child s pain keep them from vigorous activities such as running, bicycling, lifting heavy objects, or participating in strenuous sports? Never 4-7 days more than 3 weeks 1 day only more than 1 week more than 1 month 2-3 days more than 2 weeks During the past three months, how often did your child s pain keep them from moderate activities such as climbing several flights of stairs, bending, walking several blocks, lifting or stooping? Never 4-7 days more than 3 weeks 1 day only more than 1 week more than 1 month 2-3 days more than 2 weeks During the past three months, how often did your child s pain keep them from mild activities such as walking one block, climbing one flight of stairs, sitting, or standing? Never 4-7 days more than 3 weeks 1 day only more than 1 week more than 1 month 2-3 days more than 2 weeks List any other health problems that your child has. Dates Problem Health Care Provider List any mood or behavioral problems that your child has. Dates Problem Health Care Provider 6
7 Do you have any current concerns regarding your child s mood or behavior? List all family health problems including chronic pain, emotional and behavior problems and alcohol or substance abuse. Mark whether your child is aware of and/or has observed each condition. Family member Dates Type of illness Outcome Child Aware/Observed Are there any major life stresses in the family (such as divorce, separation, difficult financial burden, illness)? If yes, please list. Were any major changes in your or your child's life happening when the pain started? Please explain. What was your reaction to the pain at that time? Please explain. If your child's pain were to be better managed, how would it change their life? 7
8 How would it change your life? How would it change family relationships? If the pain continues, what kinds of things do you think your child should do? Is there anything else you would like to tell us about your child's pain and the effect it has on your child, yourself or the family? 4800 Sand Point Way NE, PO Box 5371, M/S 9G-1 Seattle, WA Phone Fax: Source: Varni, J.W., & Thompson, K.L. (1985). The Varni/Thompson Pediatric Pain Questionnaire: Form C (Child), unpublished manuscript. Modified for Children s Hospital and Regional Medical Center, Seattle, Washington All Rights Reserved. 8
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Copyright 2015 Health Vista, Inc. 305 N 2nd Street La Crescent, MN 55947 www.healthvista.net All rights reserved The information in this workbook is not to be used instead of talking to your health care
Patient Health History and Information
Patient Health History and Information Date: Age: Height: Weight: Sex: M F Dominant hand: R L Could you be or are you pregnant: Y N Reason for Therapy: Date of injury/onset of symptoms: / / Please describe
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
HEADACHE MEDICINE NEW PATIENT QUESTIONNAIRE
1 HEADACHE MEDICINE NEW PATIENT QUESTIONNAIRE Name Date Age your headaches began (or how long ago did they start? ) Do you have more than one type of headache? Yes No If yes, answer the following questions
Initial Patient Health Assessment Form
Initial Patient Health Assessment Form General Information: Patient Name:, Date: / /20 Patient s Address:. City:, State:, Zip Code: Home Phone #: - -, Work Phone #: - -, Cell #: - - E-mail address:, Date
Pain Questionnaire. Family name:... First name:... Address:...
I see a complete universe in every single human being (Dr. Still, Founder of ostepathy) Pain Questionnaire Family name:... First name:... Address:. ZIP:... City:... Phone.:... Mobile:... Insurance no.:...