PACIFIC PAIN MEDICINE - PATIENT PAIN QUESTIONNAIRE (HIPAA COMPLIANT)
Appointment Date:
*
/
Month
/
Day
Year
Date
First Name:
*
Last Name:
*
Please provide your average pain score over the last week (0 = no pain, 10 = worst pain imaginable)
*
Please Select
1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
10/10
Where is your pain located?
*
Head
Neck
Chest
Back
Hips
Arms
Hands
Legs
Feet
Abdomen
Other
Head
Face
Back of head
Top of head
Left side of head
Right side of head
Chest
Upper right side of chest
Upper left side of chest
Lower right side of chest
Lower left side of chest
Back
Upper right side of back (midback)
Upper left side of back (midback)
Lower right side of back
Lower left side of back
Hips
Left hip
Right hip
Arms
Left arm
Right arm
Left Arm
Upper arm
Middle of arm
Lower arm
Right arm
Upper arm
Middle of arm
Lower arm
Legs
Left leg
Right leg
Left Leg
Upper leg
Knee
Lower leg
Right Leg
Upper leg
Knee
Lower leg
Hands
Left hand
Right hand
Feet
Left foot
Right foot
1. How is your usual pain since your last visit with us?
*
Better
Same
Worse
2. Do you have any new areas of pain?
*
Yes
No
If yes, where?
3. Where is the worst area of pain?
*
4. How would you describe your pain?
*
Sharp
Burning
Aching
Stabbing
Other
5. Timing of the pain:
*
Occasional (present 25% of the time)
Intermittent (present 50% of the time)
Frequent (present 75% of the time)
Constant (present 90-100% of the time)
6. Intensity of pain:
*
Minimal (an annoyance)
Slight (tolerable but some activities limited by pain)
Moderate (tolerable but most activities limited by pain)
Severe (all activities limited by pain)
7. Are you experiencing any side effects from your medications?
Yes
No
If so, what?
8 Are you experiencing any NEW numbness, tingling or weakness?
Yes
No
If so, where?
9. Are you doing any exercise that makes you increase your heart rate?
*
Yes
No
If so, what?
10. What treatments have you started since your last visit? (i.e., PT, massage, injections, etc.)
11. How much does your pain interfere with the following?
General Activity
0-Does not interfere
1
2
3
4
5
6
7
8
9
10-Completely Interferes
Mood
0-Does not interfere
1
2
3
4
5
6
7
8
9
10-Completely Interferes
Walking Ability
0-Does not interfere
1
2
3
4
5
6
7
8
9
10-Completely Interferes
Normal Work
0-Does not interfere
1
2
3
4
5
6
7
8
9
10-Completely Interferes
Personal Relationships
0-Does not interfere
1
2
3
4
5
6
7
8
9
10-Completely Interferes
Sleep
0-Does not interfere
1
2
3
4
5
6
7
8
9
10-Completely Interferes
Enjoyment of Life
0-Does not interfere
1
2
3
4
5
6
7
8
9
10-Completely Interferes
12. Please select any of the following symptoms that you experience
General:
Fever
Fatigue
Weight loss
Weight gain
ENT:
Change in vision
Change in hearing
Painful swallowing
Resp:
Shortness of breath
Cough
Sleep apnea
Cardio:
Chest pain
Palpitations
High blood pressure
GI:
Constipation
Nausea
Vomiting
Heartburn
Diarrhea
Neuro:
Numbness
Headaches
Dizziness
Blackouts
Psych:
Depression
Anxiety
Suicidal thoughts
Addiction
GU:
Sexual dysfunction
Burning w/ urination
Incontinence of bowel/bladder
MS:
Sore joints
Spasms
Stiffness
Joint swelling
Heme:
Easy bruising
Blood in stool
Pale skin
Weakness
13. How satisfied are you with your pain treatments/medications?
0-Not at all
1
2
3
4
5
6
7
8
9
10-Completely
Submit
Should be Empty: