Chronic Pain Initial Assessment
An initial assessment for new patients presenting with 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 neuropsychiatric 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.

By submitting this questionnaire, you can request free pain management advice by email or telephone or through a clinic consultation.
Email address *
Name and surname
Gender
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Age
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Country of origin
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Weight in kg
Height in cm
Occupation
Relationship status
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Have you been diagnosed with a chronic illness?
Do you have any history of the following?
What investigations have been done so far?
Which of the following symptoms do you experience?
When did the pain start?
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Where is the pain located?
How would you describe your pain?
How does the pain vary?
What factors worsen your pain?
What helps you ease your pain?
What helps you ease your pain the most?
How severe was your baseline pain in the last 4 weeks?
No pain
Severe pain
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How much did the pain affect your quality of life in the last 4 weeks?
Not at all
Very much
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Rate your quality of sleep over the last 4 weeks
Very bad
Excellent
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Rate your mood over the last 4 weeks
Depressed
Happy
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Rate your anxiety over the last 4 weeks
No anxiety
Very anxious
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Rate your energy levels over the last 4 weeks
Very fatigued
Full of energy
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How much does the pain affect your job / daily activities?
Not at all
Very much
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Did you have trouble with light physical activities over the last 4 weeks?
Not at all
Very much
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Did you have trouble with strenuous physical activities over the last 4 weeks?
Not at all
Very much
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How much did the pain restrict your social activities over the last 4 weeks?
Not at all
Very much
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Rate your bowel function over the last 4 weeks?
Very bad (gas/bloating/loose stools)
Very good & regular
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Do you consume the following food products?
What exercise do you do regularly?
What stretching do you do regularly?
What meditation do you do regularly?
What vitamins / supplements do you take regularly?
What type of medications do you take regularly?
List your regular medications
Do you use any of the following substances regularly?
Further comments / notes / information
Would you like advice on how to manage your pain?
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Do you give your consent to use this information anonymously for research purposes?
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