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Pain Management Clinic

Pain Management Team

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Enquiries - All Locations

Phone: (02) 4923 8900

Fax: (02) 4947 8991

General Email Enquiries

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

Name(Required)

Date of Birth(Required)

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)

Yes

No

Please describe where on your body you feel pain the most.(Required)

Please rate your pain at its WORST in the past 24 hours.(Required)

0

1

2

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9

10

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

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2

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4

5

6

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8

9

10

0 = No pain; 10 = Pain as bad as you can imagine

Please rate your pain at its average.(Required)

0

1

2

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8

9

10

0 = No pain; 10 = Pain as bad as you can imagine

Please rate your pain right NOW.(Required)

0

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2

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5

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8

9

10

0 = No pain; 10 = Pain as bad as you can imagine

This field is hidden when viewing the form

Average

What treatments or medicines are you receiving for your pain?(Required)

In the past 24 hours, how much relief have pain treatments or medications provided?(Required)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% = No Relief; 100% = Complete Relief

In the past 24 hours, how has the pain interfered with your General Activity.(Required)

0

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0 = Does Not Interfere; 10 = Completely Interferes

In the past 24 hours, how has the pain interfered with your Mood.(Required)

0

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10

0 = Does Not Interfere; 10 = Completely Interferes

In the past 24 hours, how has the pain interfered with your Walking Ability.(Required)

0

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10

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

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10

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

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10

0 = Does Not Interfere; 10 = Completely Interferes

In the past 24 hours, how has the pain interfered with your sleep.(Required)

0

1

2

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4

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9

10

0 = Does Not Interfere; 10 = Completely Interferes

In the past 24 hours, how has the pain interfered with your enjoyment of life.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = Does Not Interfere; 10 = Completely Interferes

Roland-Morris Disability Questionnaire (RMDQ)

Full Name(Required)

First

Date of birth(Required)

DD slash MM slash YYYY

Tick the sentence if you are sure that it describes you today.

I stay at home most of the time because of my pain.

I change position frequently to try and get my pain comfortable.

I walk more slowly than usual because of my pain.

Because of my pain, I am not doing any of the jobs that I usually do around the house.

Because of my pain, I use a handrail to get up the stairs.

Because of my pain, I lie down to rest more often.

Because of my pain, I have to hold on to something to get out of an easy chair.

Because of my pain, I try to get other people to do things for me.

I get dressed more slowly than usual because of my pain.

I only stand for short periods of time because of my pain

Because of my pain, I try not to bend or kneel down.

I find it difficult to get out of a chair because of my pain.

I am in pain almost all of the time

I find it difficult to turn over in bed because of my pain

My appetite is not very good because of my pain.

I have trouble putting on my socks (or stockings) because of my pain.

I only walk short distances because of my pain

I sleep less well because of my pain.

Because of my pain, I get dressed with help from someone else.

I sit down for most of the day because of my pain.

I avoid heavy jobs around the house because of my pain.

Because of my pain, I am more irritable and bad tempered with people than usual.

Because of my pain, I go up stairs more slowly than usual.

I stay in bed most of the time because of my pain.

Enquiries
All Locations

Phone: (02) 4923 8900

Fax: (02) 4947 8991

Email: Click Here

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