Pain Questionnaire
Name Today’s Date
Date of Birth: Contact Number:
Describe the pain sensation and indicate where it starts and moves
How severe is the pain on a score 0 – 10? Please indicate how it varies.
What is the impact on your life on a score of 0 -10?
When and how did it start?
What brings it on or makes it worse?
What abolishes the pain or makes it easier?
What have you tried to ease the pain? How well did that work for you?
Does anything else happen when you get the pain?
How often do you get the pain?
How long does it last?
Since it started, how has the pain altered?
When is the pain at its worst and when at its best?
Have you had episodes of pain like this before?
Please express any opinions or secret fears that have been suggested or crossed your mind as the cause of the pain.
Do you know of have you heard of anyone with a pain like yours?
What are your hopes from today’s consultation?
Is there anything else I should know?
Bernard Shevlin
b.shevlin02@gmail.com