Which statement best describes your pain? (tick one box only) Always present (always the same intensity) Always present (level of pain varies) Often present (pain free periods last less than 6 hours) Occasionally present (pain occurs once to several times per day, lasting up to an hour) Rarely present (pain occurs every few days or weeks) Do you have any of the following medical conditions? Heart disease Ulcer or stomach disease Anaemia or other blood disease High blood pressure Kidney disease Osteoarthritis, degenerative arthritis Lung disease Depression/Anxiety Rheumatoid arthritis Diabetes Cancer Stroke or other neurological condition Other medical problems (please specify) ………………………….. Section 2 Health care – How many times in the past 3 months have you seen a general practitioner in regard to 1 times ...……. your pain? How many times in the past 3 months have you seen a medical specialist (e.g. 2 times …..……. orthopaedic surgeon) in regard to your pain? How many times in the past 3 months have you seen health professionals other than 3 times …..……. doctors (e.g. physiotherapist, chiropractor, psychologist) in regard to your pain? How many times in the past 3 months have you visited a hospital emergency department 4 in regard to your pain? Include all visits regardless of whether or not you were admitted times …..……. to the hospital from the emergency department How many times in the past 3 months have you been admitted to hospital as an inpatient 5 times …..……. because of your pain? How many diagnostic tests (e.g. X-rays, scans) have you had in the last 3 months 6 tests …..……. relating to your pain? Section 3 Medication use – List all the medications you are taking (include all prescription and over-the-counter medicines) How many days per Medicine strength (as How many do you take Medicine name (as on the label) week do you take this on the label) per day? medication?
Which statement best describes your pain? (tick one box only) Always present (always the same intensity) Always present (level of pain varies) Often present (pain free periods last less than 6 hours) Occasionally present (pain occurs once to several times per day, lasting up to an hour) Rarely present (pain occurs every few days or weeks) Do you have any of the following medical conditions? Heart disease Ulcer or stomach disease Anaemia or other blood disease High blood pressure Kidney disease Osteoarthritis, degenerative arthritis Lung disease Depression/Anxiety Rheumatoid arthritis Diabetes Cancer Stroke or other neurological condition Other medical problems (please specify) ………………………….. Section 2 – Health care 1 How many times in the past 3 months have you seen a general practitioner in regard to your pain? ...……. times 2 How many times in the past 3 months have you seen a medical specialist (e.g. orthopaedic surgeon) in regard to your pain? …..……. times 3 How many times in the past 3 months have you seen health professionals other than doctors (e.g. physiotherapist, chiropractor, psychologist) in regard to your pain? …..……. times 4 How many times in the past 3 months have you visited a hospital emergency department in regard to your pain? Include all visits regardless of whether or not you were admitted to the hospital from the emergency department …..……. times 5 How many times in the past 3 months have you been admitted to hospital as an inpatient because of your pain? …..……. times 6 How many diagnostic tests (e.g. X-rays, scans) have you had in the last 3 months relating to your pain? …..……. tests Section 3 – Medication use List all the medications you are taking (include all prescription and over-the-counter medicines) Medicine name (as on the label) Medicine strength (as on the label) How many do you take per day? How many days per week do you take this medication?
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