PEG Pain Screening Tool
This form is ONLY for patients seeing:

Dr Yi-Ching Lee (Pain Specialist) and/or Adrian Brezniak (Physiotherapist)
Please enter the date you complete this form *
MM
/
DD
/
YYYY
Please enter your FIRST name *
Please enter your LAST name *
Which specialist are you seeing? *
1. What number best describes your pain on average in the past week: *
(No pain)
(Pain as bad as you can imagine)
2. What number best describes how, during the past week, pain has interfered with your enjoyment of life? *
(Does not interfere)
(Completely interferes)
3. What number best describes how, during the past week, pain has interfered with your general activity? *
(Does not interfere)
(Completely interferes)
To compute the PEG score, add the three responses to the questions above, then divide by three to get a final score out of 10. The final PEG score can mean very different things to different patients. The PEG score, like most other screening instruments, is most useful in tracking changes over time. The PEG score should decrease over time after therapy has begun. PLEASE ENTER YOUR FINAL SCORE. *
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