Chronic Pain Assessment
1 in 5 adults suffer from chronic pain. Through this assessment, Dr Andrew Agius tries to identify various factors which may help the diagnosis and management of chronic pain and other complex psychiatric disorders where pharmaceutical medication has not provided sufficient relief.

Personal information will not be shared publicly. The results from this research will be used to identify what patients find effective in relieving their symptoms and shared anonymously so that other patients can benefit.
Email address *
What is your country of residence?
What is your occupation?
Your answer
Gender
How old are you?
What is your weight in kg?
Your answer
What is your height in cm?
Your answer
What is your relationship status?
Have you been diagnosed with a chronic illness?
Do you suffer from the following symptoms?
When did your pain start?
How long does your pain last?
How severe was your baseline pain on an average day in the last 4 weeks?
Mild
Very severe
How many episodes of breakthrough pain (increase in pain) do you get per day?
How much does the pain affect your quality of life?
Very little
Very much
How much does the pain affect your job?
Very little
Very much
Rate your energy levels over the last 4 weeks
Severe fatigue
Full of energy
Do you have problems with light physical activities?
Very little
Very much
Do you have problems with strenuous physical activities?
Very little
Very much
How much does the pain restrict your social activities?
Very little
Very much
How would you describe your pain?
Where is your pain located?
What do you find relieves your pain?
What helps the most for your pain?
Your answer
What do you find worsens your pain?
Do you take any painkillers?
List any other medication that you take daily
Your answer
Do you take any supplements or vitamins?
Rate your quality of sleep on an average night
Very bad
Very good
Rate your mood on an average day
Very depressed
Very happy
How would you rate your bowel function?
Very bad (diarrhoea/constipation/bloating)
Very good (no problems)
Have you experienced any of these in your past?
Do you use any of the following substances regularly?
What exercise do you perform regularly?
Do you consume the following food substances?
Have you done any tests that have resulted abnormal?
Your answer
Any more information or comments?
Your answer
Would you like advice from a doctor on how to manage your pain?
Can we use this information anonymously for research purposes?
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