Pain Questionnaire
Dear Patient
In order to provide an effective consultation with London Pain Clinic, it would be helpful if you could provide us with information regarding your pain.
The questionnaire takes a little time to complete in full. It is intended to give as much information about you and your condition as possible to make the consultation more productive for you.
1. Personal details:
Name (including title):
Address:
Daytime Contact No’s:
Age/Sex:
2. Site of the pain
(e.g. arm, lower back, neck)
3. Character of the pain
(e.g. sharp, burning, pricking, stabbing, aching, etc.). Please try and explain in your own words
4. When did the pain start?
5. Is there anything that precipitated the pain?
(eg: accident, illness etc.)
6. How often do you get the pain
(e.g. continuous, daily, hourly etc.)
7. Does the pain radiate to any other part of the body?
8. What things aggravate the pain
(e.g. standing, walking, etc.)
9. What medication (tablets/drugs) are you currently taking?
10. What investigations have you had for your pain?
(e.g. x rays, MRI, etc)
11. What treatments have you had and their outcome?
(e.g. had 2 epidurals but effect lasted only a few weeks). Treatments include
Medication:
Physiotherapy:
Alternative medicine:
Nerve blocks (e.g. epidural):
Surgery:
Advanced pain management techniques (e.g. spinal cord stimulator):
12. Do you have any other symptoms associated with your pain
(e.g. difficulty in dressing etc.)
13. Do you have any medical illnesses?
(e.g. asthma, diabetes, high blood pressure etc.)
14. What previous surgeries have you had?
(e.g. appendix, hip replacement etc.)
15. Please provide any other information you feel is relevant to your case
(optional)
Thank you for taking the time to complete this questionnaire. Please note that the outcome will be based on the information you have provided. Therefore, London Pain Clinic accepts no responsibility for advice/information given relating to any incomplete, inaccurate or incorrect information you have provided.
