Musculoskeletal Questionnaire Step 1 of 3 33% HiddenForm New Patient Musculoskeletal Supplements Injectables HiddenDoctor's NameDr. David JaaDr. Ping JaaDr. Paul PaytonDoctor's NameDr. David JaaDr. Ping JaaDr. Paul PaytonHiddenPatient's Name Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Patient's Name Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last HiddenAddress Street Address City State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Address Street Address City State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country HiddenPhonePhoneHiddenEmail Email Measuring Your PainPlease describe your pain and how it occurred:How long have you felt this pain? Where is this pain?Please be as specific as possible, e.g. Upper arm, lower arm or hand? Leg above knee or below knee? Middle back or lower back?What is your pain level right now?Highest pain level in the past week?Lowest pain level in the past week?Usual pain level in the past week? Describing Your PainFor each of the following word groups, please select the word that best applies. Leave blank if none apply.Pain Description 1 Flickering Quivering Pulsing Throbbing Beating Pounding N/A Pain Description 2 Jumping Flashing Shooting N/A Pain Description 3 Pricking Boring Drilling Stabbing Lanciating N/A Pain Description 4 Sharp Cutting Lacerating N/A Pain Description 5 Pinching Pressing Gnawing Cramping Crushing N/A Pain Description 6 Tugging Pulling Wrenching N/A Pain Description 7 Hot Burning Scalding Searing N/A Pain Description 8 Tingling Itching Smarting Searing N/A Pain Description 9 Dull Sore Hurting Aching Heavy N/A Pain Description 10 Tender Taut Rasping Splitting N/A Pain Description 11 Tiring Exhausting N/A Pain Description 12 Sickening Suffocating N/A Pain Description 13 Fearful Frightful Terrifying N/A Pain Description 14 Punishing Gruelling Cruel Vicious N/A Pain Description 15 Wretched Blinded N/A Pain Description 16 Annoying Troublesome Miserable Intense N/A Pain Description 17 Spreading Radiating Penetrating Piercing N/A Pain Description 18 Tight Numb Drawing Squeezing Tearing N/A Pain Description 19 Cool Cold Freezing N/A Pain Description 20 Nagging Nauseating Agonising Dreadful Torturing N/A Pain TreatmentsSince your pain began, which of the following have you seen about it? Acupuncturist Anaesthetist Chiropractor Homeopath Hypnotherapist Neurologist Neurosurgeon Occupational Therapist Orthopaedic Surgeon Physiotherapist Psychologist Psychiatrist Rheumotologist Pain Clinic General Practitioner Others (detail below) Which of the above have been most helpful? Based on your experiences so far, what do you realistically expect will happen to your pain in the coming months?Get worseStay the sameReduce by 25%Reduce by 50%Reduce by 75%Completely curedIf your pain could be reduced but not completely, how much of a reduction (%) would there need to be for you live with it? Do you think 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 Questions?Are there questions you would like answered after your assessment at this pain clinic?Increased Medication?Do you think you need more medication, or stronger medication, than you are currently taking? Agree Strongly Agree Unsure Disagree Disagree Strongly Current MedicationsPlease list all medications you are taking at present. Include dosage, how often, side effects and date started.Past MedicationsPlease list all medications have taken in the past. Include dosage, how often, side effects and date started.AllergiesPlease list any allergies you may have. Include dosage, how often, side effects and date started.CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ