PAIN-QUESTIONNAIRE

SUMMARY

THE PAIN QUESTIONNAIRE
(Below is a sample pain questionnaire)

Reason for Presentation:
DEMOGRAPHICS (Age, sex):

PRESENTING COMPLAINT (Brief note on presenting complaint):

PAIN (Current symptoms including pain score, pattern, radiation, associated findings such as neuralgia/radicular pain):

ASSOCIATED PAIN FINDINGS (Such as allodynia to mechanical vs. thermal stimuli & sensitisation):

History/Discussion:
BRIEF HISTORY (History of injury, date, procedures):

BACKGROUND HISTORY (Co-morbidities):

SLEEP (Duration & quality of sleep):

WORK (Information on what work the patient does and what it involves):

ACTIVITY (Is the patient able to perform work-related, self-maintenance & leisure activities? Duration?):

THERAPY (Details on present therapies, including physiotherapy, hydrotherapy, psychological interventions & home-exercise):
Physio:Psychiatrist:Exercise:

SOCIAL STATUS (Is the patient currently married/partnered? How many children?):

PSYCHOMETRIC TESTING (Details on psychometric & pain questionnaires/testing if available, such as PSEQ, OMPQ, ODI):

CURRENT MEDS (Details on current medications):

PAST MEDS (Details on analgesics trialled previously):

REFERRING DOCTOR (Details of the referring doctor, such as the patient’s general practitioner):

INSURANCE COVER (Details on the patient’s current insurance coordinator):

Clinical Assessment:
ON EXAMINATION (Examination findings):

SCANS (Recent imaging investigations):

Management:
IMPRESSION:
Organic causes of the patient’s pain symptoms?Is widespread pain secondary to central sensitization present?Is opioid tolerance/dependence present?Is physical deconditioning present?Is depression, anxiety, stress present?

MANAGEMENT PLAN:
Details on an appropriate pain management programMedications or changes if appropriateProcedures, repeat imaging as appropriate (note that a formal request to the insurer for approval for the proposed pain management program/procedure may be required)

Reference(s)

Cifu, D.X. (2020). Braddom’s physical medicine and rehabilitation. Elsevier. Get it on Amazon.
Cuccurullo, S. (2019). Physical medicine and rehabilitation board review. New York: Demosmedical. Get it on Amazon.
O’Young, B., Young, M.A. and Stiens, S.A. (2008). Physical Medicine and Rehabilitation Secrets. Mosby. Get it on Amazon.