PAIN SERVICE REFFERAL QUESTIONNAIRE
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1 PAIN SERVICE REFFERAL QUESTIONNAIRE We would appreciate you taking some time to answer this questionnaire. It asks about your pain, and how your pain affects your life and this information is helpful to the Pain Service in prioritising your case and making treatment recommendations. Please return to the Pain Service in the enclosed postage paid envelope. DESCRIBING YOUR PAIN Where is Your Pain? On the diagram below please shade the areas where you experience pain. Put an X on the area that hurts the most. Left Right Right Left How long have you had your pain? (Years) (Months)
2 Please circle the words that best describe your pain Pulsing Throbbing Beating Pounding Quivering Jumping Flashing Shooting Pricking Boring Drilling Stabbing Sharp Cutting Lacerating Pinching Pressing Tiring Exhausting Sickening Suffocating Fearful Frightful Terrifying Punishing Gruelling Cruel Vicious Gnawing Cramping Crushing Tugging Pulling Wrenching Hot Burning Scalding Searing Tingling Itchy Smarting Stinging Dull Aching Sore Killing Wretched Blinding Unfair Shameful Terrible A Weakness Hurtful Torturing Agonising Nauseating Hurtful Heavy Tender Taut Rasping Splitting Cool Cold Freezing Spreading Radiating Penetrating Piercing Tight Numb Drawing Squeezing Intense Unbearable Nagging Dreadful Annoying Troublesome Discomforting Miserable Distressing Horrible Excruciating WORK 1. What was your occupation before your pain/injury: 2. What is your current work status? Please tick ( ) the relevant box(s) below to indicate your work status right now: Full time paid work Part time paid work Hours per week Volunteer/Unpaid work Hours per week Home duties Retired Studying / Retraining Unemployed due to pain Unemployed for other reason(s) Reason Future work plans (if unemployed): I am actively involved in the process of returning to paid or unpaid work I do intend to return to paid or unpaid work, but right now I am intending to return to paid or unpaid work
3 HOW PAIN AFFECTS YOU Circle the one number that describes how, during the last 24 hours, pain has interfered with your: 1. General Activity 2. Mood 3. Walking Ability 4. Normal Work (includes both work outside the home and housework) 5. Relations With Other People 6. Sleep 7. Enjoyment of life
4 Please e how you are that you can do the following things at present (despite the pain). To indicate your answer, circle one of the numbers on the scale under each item, where 0 = at all and 6 = completely. Remember, this questionnaire is asking whether or you have been doing these things, but rather how you are that you can do them at present. 0 =, 6 = 1. I can enjoy things, despite the pain. 2. I can do most of the household chores (e.g. tidying-up, washing dishes, etc) despite the pain. 3. I can socialise with my friends or family members as often as I used to do, despite the pain. 4. I can cope with my pain in most situations. 5. I can do some form of work, despite the pain. ( Work includes housework, paid and unpaid work). 6. I can still do many of the things I enjoy doing, such as hobbies or leisure activity, despite the pain. 7. I can cope with my pain without medication. 8. I can still accomplish most of my goals in life, despite the pain. 9. I can live a normal lifestyle, despite the pain. 10. I can gradually become more active, despite the pain.
5 HEALTHCARE How many times in the past 3 months have you seen any of the following in regard to pain? General practitioner / family doctor Medical specialists (e.g. orthopaedic surgeon, neurologist, rheumatologist) Health professionals other than doctors (e.g. nurse, physiotherapist, occupational therapist, psychologist) Alternative/Complimentary health professionals (e.g. homeopath, massage therapist, acupuncturist) A hospital emergency department Admitted in hospital for more than one night because of your pain Number of Times MEDICATIONS What are your current medications? Please list all of the medications you are currently taking. Indicate what dose, how often you take them, and for what problem. Please list both over-the-counter and prescription medications (continue on a separate page if necessary). Name and dose is written on the medication container. 1 Medication Dose (mg) How often Problem used for
6 Have you ever taken any of the following medications for your pain? (Please tick ( ) one box for each medication). If you experienced side effects when taking these medications, please write these down. Have Not Amitriptyline (Amitrip, Amirol) Nortriptyline (Norpress, Allegron) Imipramine (Tofranil) Dothiepin(Dopress, Prothiaden) Clonazepam (Paxam, Rivotril) Sodium Valproate (Epilim) Phenytoin (Dilantin) Carbamazepine (Tegretol) Gabapentin(Neurontin, Nupentin) Clonidine (Catapres) Baclofen (Pacifen) Mexiletine (Mexitil) Morphine (Sevredol, M-eslon) Pethidine Tramadol(Arrow-tramadol, Tramal) Oxycodone (Oxycontin/Oxynorm) Codeine(Codalgin, Panadeine) Paracetamol (Panadol) Diclofenac (Diclax, Voltaren) Ibuprofen (Brufen, Nurofen) Celecoxib (Celebrex) Other (name) Tried No Benefit Some Benefit Marked Benefit Side Effects Do you think you need more pain medication, or stronger medication, than you are currently taking? (agree strongly) (agree) (unsure) (disagree) (disagree strongly) In the last week, have you had side effects from pain medications or treatments? Please circle the one number that best shows how severe the side effects have been. No side Severe Side
7 effects Effects
8 FINALLY What do you feel are your main problems related to your pain? What do you hope to achieve by attending the pain service at North Shore Hospital?
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PAIN INFORMATION SHEET PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE SENSATIONS DESCRIBED BELOW. PLEASE USE THE APPROPRIATE SYMBOL & INCLUDE ALL AREAS. **** ==== OOOO XXXX //// ACHE **** NUMBNESS
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DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT Patient (First) (Middle) (Last) Address City State Zip E-mail address Home Phone # Cell Phone # Would you like an appointment reminder? Text( ) Call(