Royal Hobart Hospital Effective Date: August 2016 Review Date: August 2017 Persistent Pain Service Patient Questionnaire English - Consult your doctor or another health professional if you need help completing this questionnaire. Dutch - Raadpleeg uw arts of een andere gezondheidsberoeps als u hulp voltooiend deze vragenlijst nodig hebt. French - Consultez un votre docteur ou un professionnel de la santé différent si vous avez besoin de l'aide remplissant ce questionnaire. German - Fragen Sie Ihren Arzt oder anderen medizinischen Fachpersonal, wenn Sie brauchen Hilfe beim Ausfüllen dieses Fragebogens. Greek - Συμβουλευθείτε το γιατρό σας ή έναν άλλο προσφέροντα ιατρικές υπηρεσίες εάν χρειάζεστε τη βοήθεια συμπληρώνοντας αυτό το ερωτηματολόγιο. Italian - Consulti il vostro medico o un altro professionista del settore medico-sanitario se avete bisogno dell'aiuto che compila questo questionario. Spanish – Consulte con su médico u otro profesional de salud si necesita ayuda para contestar este questionario. Return completed questionnaire to: Fax: 03 6222 7526 or Mail: PO Box 1061, Hobart 7000
Transcript
Royal Hobart Hospital
Effective Date: August 2016
Review Date: August 2017
Persistent Pain Service
Patient Questionnaire
English - Consult your doctor or another health professional if you need help completing this questionnaire.
Dutch - Raadpleeg uw arts of een andere gezondheidsberoeps als u hulp voltooiend deze vragenlijst nodig hebt.
French - Consultez un votre docteur ou un professionnel de la santé différent si vous avez besoin de l'aide
remplissant ce questionnaire.
German - Fragen Sie Ihren Arzt oder anderen medizinischen Fachpersonal, wenn Sie brauchen Hilfe beim Ausfüllen
dieses Fragebogens.
Greek - Συμβουλευθείτε το γιατρό σας ή έναν άλλο προσφέροντα ιατρικές υπηρεσίες εάν χρειάζεστε τη βοήθεια
συμπληρώνοντας αυτό το ερωτηματολόγιο.
Italian - Consulti il vostro medico o un altro professionista del settore medico-sanitario se avete bisogno dell'aiuto che
compila questo questionario.
Spanish – Consulte con su médico u otro profesional de salud si necesita ayuda para contestar este questionario.
Return completed questionnaire to:
Fax: 03 6222 7526 or Mail: PO Box 1061, Hobart 7000
2
PERSISTENT PAIN SERVICE - QUESTIONNAIRE
The Royal Hobart Hospital Persistent Pain Service has received a referral regarding your persistent pain. This
questionnaire is required to help with planning and the making treatment recommendations.
Please return completed questionnaire to:
Fax: 03 6222 7526 or Mail: PO Box 1061, Hobart 7000
3. Which statement describes the typical pattern of your main pain? Please tick the best option.
□ Always or almost always present, constant intensity
□ Always or almost always present, variable intensity
□ Recurring irregularly (eg: like headache)
□ Recurring regularly (eg: premenstrual pain)
How long has your main pain been present? Please tick the best option.
□ 1 month or less
□ 1 month to 6 months
□ 6 months to 12 months
□ 12 months to 3 years
□ 3 to 5 years
□ 5 to 10 years
□ more than 10 years
What month and year did the pain start __________________________
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5. How did your main pain begin? Please tick the best option.
□ Accident at work
□ Accident at home
□ Motor vehicle crash
□ After surgery
□ Related to cancer
□ Related to another illness (specify) __________________________________
□ Pain just began, no clear reason
□ Other _______________________________________________________
9
Kessler-10 Developed by the World Health Organisation to measure psychological distress and well-being.
Please circle the number that best describes
how you felt
None
of the
time
A little
Some
of the
time
A lot
All the
time
1. In the last 4 weeks, how often did you feel tired out
for no good reason?
1
2
3
4
5
2. In the last 4 weeks, how often did you feel nervous?
1
2
3
4
5
3. In the last 4 weeks, how often did you feel so
nervous that nothing could calm you down?
1
2
3
4
5
4. In the last 4 weeks, how often did you feel hopeless?
1
2
3
4
5
5. In the last 4 weeks, how often did you feel restless
or fidgety?
1
2
3
4
5
6. In the last 4 weeks, how often did you feel so
restless that you could not sit still?
1
2
3
4
5
7. In the last 4 weeks, how often did you feel
depressed?
1
2
3
4
5
8. In the last 4 weeks, how often did you feel that
everything was an effort?
1
2
3
4
5
9. In the last 4 weeks, how often did you feel so sad
that nothing could cheer you up?
1
2
3
4
5
10. In the last 4 weeks, how often did you feel
worthless?
1
2
3
4
5
Office use: ____________________________________
10
Pain Self-Efficacy Questionnaire
Developed in the 1980s by Michael Nicholas (psychologist) to assess the confidence that people with ongoing pain have in performing
activities while in pain.
Please rate how confident you are that you can do the following things at present despite the pain. To indicate
your answer, circle one of the numbers on the scale under each item, where 0 = not at all confident and 6 =
completely confident. Remember, this questionnaire is not asking whether or not you have been doing these
things, but rather how confident you are that you can do them at present, despite the pain.
1. I can enjoy things, despite the pain.
2. I can do most of the household chores (eg. tidying-up, washing dishes etc.) despite the pain.
3. I can socialise with my friends or family members as often as I used to do, despite the pain.
4. I can cope with my pain in most situations.
5. I can do some form of work, despite the pain (“work” includes housework, paid and unpaid work).
Completely
confident
Not at all
confident
0 1 2 3 4 5 6
Completely
confident
Not at all
confident
0 1 2 3 4 5 6
Completely
confident
Not at all
confident
0 1 2 3 4 5 6
Completely
confident
Not at all
confident
0 1 2 3 4 5 6
Completely
confident
Not at all
confident
0 1 2 3 4 5 6
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6. I can still do many of the things I enjoy doing, such as hobbies or leisure activities, despite the pain.
7. I can cope with my pain without medication.
8. I can still accomplish most of my goals in life, despite the pain.
9. I can live a normal lifestyle, despite the pain.
10. I can gradually become more active, despite the pain.
Completely
confident
Not at all
confident
0 1 2 3 4 5 6
Completely
confident
Not at all
confident
0 1 2 3 4 5 6
Completely
confident
Not at all
confident
0 1 2 3 4 5 6
Completely
confident
Not at all
confident
0 1 2 3 4 5 6
Completely
confident
Not at all
confident
0 1 2 3 4 5 6
12
Roland Morris Disability Questionnaire (modified)
The Roland Morris Disability Questionnaire is used around the world to measure the amount of disability caused by a range of health conditions including
persistent pain.
When pain hurts, you may find it difficult to do some things you normally do. This list contains sentences people have used to describe
themselves when they have pain. You may find that some stand out more than others because they describe you today. When you read a
sentence that describes you today, put a tick against it. If the sentence does not describe you, then leave the box blank and go on to the next
one. Remember; only tick the sentences if you are sure that it describes you today.
1. I stay at home most of the time because of my pain ______________________________ □ 2. I change position frequently to try to get my pain comfortable______________________ □ 3. I walk more slowly than usual because of my pain _______________________________ □ 4. Because of my pain, I am not doing any of the jobs that I usually do around the house __ □ 5. Because of my pain, I use a handrail to get up stairs _____________________________ □ 6. Because of my pain, I lie down to rest more often _______________________________ □ 7. Because of my pain, I have to hold on to something to get out of an easy chair ________ □ 8. Because of my pain, I try to get other people to do things for me ___________________ □ 9. I get dressed more slowly than usual because of my pain _________________________ □ 10. I only stand up for short periods of time because of my pain _______________________ □ 11. Because of my pain, I try not to bend or kneel down _____________________________ □ 12. I find it difficult to get out of a chair because of my pain __________________________ □ 13. I am in pain almost all of the time ____________________________________________ □ 14. I find it difficult to turn over in bed because of my pain __________________________ □ 15. My appetite is not good because of my pain ____________________________________ □ 16. I have trouble putting on my socks (or stockings) because of my pain _______________ □ 17. I only walk short distances because of my pain _________________________________ □ 18. I sleep less well because of my pain __________________________________________ □ 19. Because of my pain, I get dressed with help of someone else ______________________ □ 20. I sit down for most of the day because of my pain _______________________________ □ 21. I avoid heavy jobs around the house because of my pain __________________________ □ 22. Because of my pain, I am more irritable and bad tempered with people than usual ______ □ 23. Because of my pain, I go up stairs more slowly than usual ________________________ □ 24. I stay in bed most of the time because of my pain. _______________________________ □
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HEALTHCARE UTILISATION
1. How many times in the past 3 months have you seen a general practitioner in regard to pain?
________ times
2. How many times in the past 3 months have you seen medical specialists (eg. orthopaedic surgeon or
neurologist) in regard to pain? _________ times
3. How many times in the past 3 months have you seen health professionals other than doctors (eg.
physiotherapist, chiropractor or psychologist) in regard to pain? ___________ times
4. How many times in the past 3 months have you visited a hospital emergency department in regard to
pain? _______ times
5. For how many days in total over the past 3 months have you been in hospital as an inpatient because of
pain? ______ days
MANAGEMENT
1. Please indicate (tick) any of the following treatments that you have tried, and whether or not they were
helpful:
Treatment Never
Tried
Helpful No help Pain
worse
Ongoing
Surgery
Nerve blocks
TENS
Bed rest in hospital
Bed rest with traction
Psychology
Hypnosis
Relaxation
Acupuncture
Chiropractic
Osteopathic
Physiotherapy (hands on)
Hydrotherapy
2. Please list any operations you have had relating to your pain:
Type of Operation Year Surgeon
3. Please list all the medications you are taking for pain at present:
Medication
name
Dose How
often
Benefits (tick) Side effects
(list)
none slight moderate marked
4. In the last week, have you had side effects from pain medications or treatments? Please circle the one number
that best shows how severe the side effects have been.
5. Please list all the medications you are taking for reasons other than pain at present:
6. What other medications can you remember trying for you pain?
7. Do you think you need more or stronger medication (circle)?
8. Do you smoke cigarettes? No / Yes
9. Please circle how many days of the week you take alcohol
□ Non drinker □ Less than 1 day/week □ 1 day/week
□ 1-5 days/week □ More than 5 days/week
No side
effects
0 1 2 3 4 5 6 7 8 9 10 10
Severe side
effects
Agree strongly Disagree
strongly
0 1 2 3 4 5 6
Unsure
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10. If you take alcohol, how many standard drinks do you usually take at a time?
□ 1-2 □ 3-4 □ 5-6 □ 6-7 □ 7-8 □ 8-15 □ more than 15
11. Do you ever take alcohol to relieve your pain? No / Yes
12. Do you use other substances? No / Yes
13. If you attend for an assessment, are there particular questions you would like answered?
14. If you attend this service, what will you be hoping to achieve?
15. Your Story
If you wish to, this section is reserved for you to tell your story. This may be the story of your pain and how it
affects you and your lifestyle, or what you do now to limit your pain’s effect on your life. (Feel free to attached
further sheets)
16. Who helped you to fill in this questionnaire? (tick the box)
□ No help needed □ Family member □ Friend □ Health professional □ Other
Thank you for completing the Referral Questionnaire. If you would like further information about
persistent pain, you may like to visit: www.hnehealth.nsw.gov.au/pain
Teaching and research
We would like your permission to use these answers for teaching and research, after removing all identifying details like
names, addresses etc. This helps us improve our understanding of pain and its effects on people’s lives, and measure the
