Pain Stimulation Patients

Please allow 20 minutes to complete this questionnaire below in its entirety.

If you have any questions, please phone our rooms on (02) 4923 8900.

Brief Pain Inventory

DD slash MM slash YYYY
Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these kinds of pain today?(Required)
Please rate your pain at its WORST in the past 24 hours.(Required)
0 = No pain; 10 = Pain as bad as you can imagine
Please rate your pain at its LEAST in the past 24 hours.(Required)
0 = No pain; 10 = Pain as bad as you can imagine
Please rate your pain at its average.(Required)
0 = No pain; 10 = Pain as bad as you can imagine
Please rate your pain right NOW.(Required)
0 = No pain; 10 = Pain as bad as you can imagine
Hidden
In the past 24 hours, how much relief have pain treatments or medications provided?(Required)
0% = No Relief; 100% = Complete Relief
In the past 24 hours, how has the pain interfered with your General Activity.(Required)
0 = Does Not Interfere; 10 = Completely Interferes
In the past 24 hours, how has the pain interfered with your Mood.(Required)
0 = Does Not Interfere; 10 = Completely Interferes
In the past 24 hours, how has the pain interfered with your Walking Ability.(Required)
0 = Does Not Interfere; 10 = Completely Interferes
In the past 24 hours, how has the pain interfered with your Normal Work (includes both work outside the home and housework).(Required)
0 = Does Not Interfere; 10 = Completely Interferes
In the past 24 hours, how has the pain interfered with your relation with other people.(Required)
0 = Does Not Interfere; 10 = Completely Interferes
In the past 24 hours, how has the pain interfered with your sleep.(Required)
0 = Does Not Interfere; 10 = Completely Interferes
In the past 24 hours, how has the pain interfered with your enjoyment of life.(Required)
0 = Does Not Interfere; 10 = Completely Interferes

Roland-Morris Disability Questionnaire (RMDQ)

Full Name(Required)
DD slash MM slash YYYY
Tick the sentence if you are sure that it describes you today.