Musculoskeletal Questionnaire If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Doctor's Name: * Dr. Ping Jaa Dr. David Jaa Patient First Name: * Patient Surname: * Patient: Address * Patient Phone Number: * Patient Email: * 1a. Please describe the pain problem that brings you to the clinic and how it occurred 1b. How long has the pain been present? 2. Please describe where your pain is, being as specific as possible. eg. Upper arm, lower arm or hand? Leg above knee or below knee, middle back or lower back? 3a. How intense is your pain right now? 0 1 2 3 4 5 6 7 8 9 10 3b. What were the highest and lowest levels of your pain in the last week (select 2 choices)? 012345678910 3c. What was the usual level of your pain in the last week? 0 1 2 3 4 5 6 7 8 9 10 4. Some of the words below describe your present pain. Select only those words which best describe it. If more than one word in a group describes your pain, choose the one that describes it best. If no words in a group describe your pain, leave it and go onto the next one. 1 flickering quivering pulsing throbbing beating pounding 2 jumping flashing shooting 3 pricking boring drilling stabbing lancinating 4 sharp cutting lacerating 5 pinching pressing gnawing cramping crushing 6 tugging pulling wrenching 7 hot burning scalding searing 8 tingling itching smarting searing 9 dull sore hurting aching heavy 10 tender taut rasping splitting 11 tiring exhausting 12 sickening suffocating 13 fearful frightful terrifying 14 punishing gruelling cruel vicious 15 wretched blinded 16 annoying troublesome miserable intense 17 spreading radiating penetrating piercing 18 tight numb drawing squeezing tearing 19 cool cold freezing 20 nagging nauseating agonising dreadful torturing 5. Since your pain began, which of the following have you seen about it? acupuncturistanaesthetistchiropractorhomeopathhypnotherapistneurologistneurosurgeonoccupational therapistorthopaedic surgeonphysiotherapistpsychologistpsychiatristrheumotologistpain clinicgeneral practitionerothers (detail below) 6. Which of the above have you found helpful so far? 7. Based on your experiences so far, what do you realistically expect will happen to your pain in the coming months? It will get worse It will not change It will be reduced by 25% It will be reduced by 50% It will be reduced by 75% It will be completely cured 8. If your pain could be reduced, but not completely, how much of a reduction (%) would there need to be for you to feel you could live with it? 9. Do you think that your pain may be due to a serious disease which your doctors have not found or have not told you about? Yes No Not sure 10. Are there any questions you would like answered after your assessment at this pain clinic? 11a. Do you think you need more medication, or stronger medication, than you are currently taking? Agree strongly Agree Unsure Disagree Disagree strongly 11b. Please list all or any medications you are taking at present. Include dosage, how often, side affects and date started 11c. Please list all or any medications you have taken in the past. Include dosage, how often, side affects and date started 11d. Please list any allergies you may have Confirm that you are not a bot *
