Please fill out the following questionnaire before your scheduled appointment.

Your have been has referred for evaluation and assistance with your problem. In order to facilitate your care, it is essential that we learn as much about you as we can. The following questionnaire asks many questions regarding your problems. Some questions may seem unrelated to your problem, and even unnecessary.

All data is treated as strictly confidential

1. Your Name
2. Email
3. Where is your pain /discomfort /problem?
4. Pain Area Back Leg Back & Leg Neck Arm Neck & Arm Head Chest Abdomen Pelvis
5. Other
6. How long have you had this now for?
7. Duration 1 2 3 4 5 6 7 8 9 10 11 12
8. Scale Days Weeks Month Years
9. Did it start suddenly or gradually?
10. How long Gradually Sudden Onset
11. Did anything happen to cause it?
12. Cause known? Yes No
13. Text
14. How would you rate this at its worst
15. Rate Pain 1 2 3 4 5 6 7 8 9 10
16. How would you rate it on average?
17. Average Pain 1 to 10 1 2 3 4 5 6 7 8 9 10
18. What makes it worse?
19. Worse? Rest Movement Early in the morning Towards the end of the day Walking Getting up from a chair/bed Standing Sitting Sport
20. OtherPlease add text here
21. Is it there constantly?
22. Is it constant? Yes No
23. Does it disturb you sleep?
24. Disturb Sleep Yes No
25. How would you describe it?
26. Please describe it Ache Burning Stinging Shooting
27. Other
28. What do you think is the cause of your pain?
29. Please provide informationAnswer here
30. Have you had this problem before?
31. History of similar? Yes No
32. Are you taking pain killers at present for this?
33. Any Pain Killers? Yes No
34. What are you taking / What have you tried?
35. Tell us about your pain killers Dont know Paracetamol Ibuprofen Diclofenac/Voltarol Nurofen Arcoxia Celebrex Codiene Dihydrocodiene Tramadaol Morphine Oxycodone Fentanyl Buprenorphine Diazepam/Lorazepam/Clonazepam Gabapentin/Pregabalin Amitrilline/Nortriptlline Duloxetine
36. Other
37. Have any investigations been done?
38. Any medical proceedures? Yes No
39. What was done Dont know Select Blood Test Xray MRIs CT Scans Nerve conduction studies
40. Other TreatmentPlease add your treatment here.
41. What other therapies have you had for this?
42. Which Therapies Select Dont know Physiotherapy Hydrotherapy Injections Radiofrequency Neuroplasty Vertbroplasty/Kyphoplasty Surgery Spinal Cord Stimulator Osteopathy Acupuncture TENS
43. Other Add here
44. Questions you would like answered
45. Any other QuestionsPlease feel free to add any questions you have here.

 

cforms contact form by delicious:days