Pain

If you intend to come to see the doctor or nurse about Pain, it might help if you could print out and complete this questionnaire, and bring it along with you when you come to see your doctor.

If you are feeling Anxious or Depressed as well, it would help if you could also complete another questionnaire to bring- click here

Name ......................... Age .

Telephone No. ................ Date

1. When did you first feel the pain?

2. What were you doing?

3. Describe the pain e.g. aching, burning, stabbing, gripping, bursting, throbbing,

discomfort. ..............................

4. How many times per day, per week or month
does the pain occur?

5. How long does it last?................

6. Is the pain coming more or less often?

7. Does anything ease the pain? (e.g. aspirin, food, resting, antacid, etc)

8. Does anything bring it on or make it worse?

9. Does anything else happen to you round about the time you have the pain?.....................

10. Does the pain make you want to stay still or move around? .....................

11. What time of day, week or month is the pain worse? ......................

12. why did you select today to have it sorted out?

13. Does anyone else have a problem like yours?

14. Could you please express any opinions, theories or secret fears that may have crossed your mind or been suggested as to the cause of the pain.

15. Is there anything else I should know?

16. Please draw in the exact position of the pain and mark where is spreads or moves.

(with thanks to Dr Bernard Shevlin, a GP in Stoke on Trent)