Musculoskeletal Questionnaire - IMH Gold Coast

Step 1 of 3

33%

Musculoskeletal Treatment

Hidden

Form

Hidden

Doctor's Name

Hidden

Patient's Name

Prefix First Last

Patient's Name

Prefix First Last

Hidden

Address

Street Address City State Postcode Country

Address

Street Address City State Postcode Country

Hidden

Phone

Hidden

Measuring Your Pain

Please 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 Pain

For each of the following word groups, please select the word that best applies.

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 Treatments

Since 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)

Others you've seen:

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?

If 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

Not Sure

Questions?

Are there questions you would like answered after your assessment at this pain clinic?

Increased Medication?(Required)

Do you think you need more medication, or stronger medication, than you are currently taking?

Agree Strongly

Agree

Unsure

Disagree

Disagree Strongly

Current Medications

Please list all medications you are taking at present. Include dosage, how often, side effects and date started.

Past Medications

Please list all medications have taken in the past. Include dosage, how often, side effects and date started.

Allergies

Please list any allergies you may have. Include dosage, how often, side effects and date started.

CAPTCHA

This field is for validation purposes and should be left unchanged.