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.
* Required
Email address
*
Your email
Name and surname
Your answer
Gender
Female
Male
Prefer not to say
Other:
Clear selection
Age
<18
19-29
30-39
40-49
50-59
60-69
70-79
>80
Other:
Clear selection
Country of origin
Malta
Romania
U.K.
Italy
Germany
Spain
Other:
Clear selection
Weight in kg
Your answer
Height in cm
Your answer
Occupation
Your answer
Relationship status
In a relationship
Single
Married
Separated
Divorced
Prefer not to say
Other:
Clear selection
Have you been diagnosed with a chronic illness?
Fibromyalgia
ME / Chronic fatigue syndrome
Migraines
Tension headaches
Irritible bowel syndrome (IBS)
Temporomandibular joint syndrome (TMJ)
Restless legs syndrome (RLS)
Slipped disc
Sciatica
Arthritis
Anxiety
Depression
Obsessive compulsive disorder (OCD)
Hypothyroidism
Other:
Do you have any history of the following?
Family history of fibromyalgia / chronic pain
Psychological trauma / abuse
Physical trauma (e.g. MVA / fall from height)
Severe viral infection (e.g. EBV)
Ongoing chronic stress (e.g. abusive marriage, work-related)
Other:
What investigations have been done so far?
X-ray
MRI
Blood tests
CT scan
PET scan
Psychiatrist assessment
Other:
Which of the following symptoms do you experience?
Persistent pain
Chronic fatigue
Difficulty falling asleep
Waking up several times during the night
Waking up tired
Feeling anxious
Depressed mood
Overthinking
Constant worrying
Irritibility
Anger
Panic
Other:
When did the pain start?
<3months ago
<1year ago
1-5years ago
>5years ago
>10years ago
>20years ago
>30years ago
Clear selection
Where is the pain located?
Everywhere
Head
Neck
Lower back
Upper back
Arms
Legs
Feet
Abdomen
Pelvis
Other:
How would you describe your pain?
Deep bone pain
Burning
Shock-like
Knife-like
Tingling
Numbness
Compressive
Pulling
Other:
How does the pain vary?
It's constant
Comes and goes
Good days and bad days
Worse at night
Affected by stress
Affected by food
Other:
What factors worsen your pain?
Stress
Lack of sleep
Worrying
Anxiety
Exertion
Exercise
Sitting for long periods
Lying down in bed
Feeling depressed
Eating certain foods
Other:
What helps you ease your pain?
Painkiller tablets
Cannabis
CBD oil
Meditation
Exercise
Rest
Yoga
Pilates
Physiotherapy
A good night's sleep
A healthy diet
Other:
What helps you ease your pain the most?
Your answer
How severe was your baseline pain in the last 4 weeks?
No pain
1
2
3
4
5
6
7
8
9
10
Severe pain
Clear selection
How much did the pain affect your quality of life in the last 4 weeks?
Not at all
1
2
3
4
5
6
7
8
9
10
Very much
Clear selection
Rate your quality of sleep over the last 4 weeks
Very bad
1
2
3
4
5
6
7
8
9
10
Excellent
Clear selection
Rate your mood over the last 4 weeks
Depressed
1
2
3
4
5
6
7
8
9
10
Happy
Clear selection
Rate your anxiety over the last 4 weeks
No anxiety
1
2
3
4
5
6
7
8
9
10
Very anxious
Clear selection
Rate your energy levels over the last 4 weeks
Very fatigued
1
2
3
4
5
6
7
8
9
10
Full of energy
Clear selection
How much does the pain affect your job / daily activities?
Not at all
1
2
3
4
5
6
7
8
9
10
Very much
Clear selection
Did you have trouble with light physical activities over the last 4 weeks?
Not at all
1
2
3
4
5
6
7
8
9
10
Very much
Clear selection
Did you have trouble with strenuous physical activities over the last 4 weeks?
Not at all
1
2
3
4
5
6
7
8
9
10
Very much
Clear selection
How much did the pain restrict your social activities over the last 4 weeks?
Not at all
1
2
3
4
5
6
7
8
9
10
Very much
Clear selection
Rate your bowel function over the last 4 weeks?
Very bad (gas/bloating/loose stools)
1
2
3
4
5
6
7
8
9
10
Very good & regular
Clear selection
Do you consume the following food products?
Dairy products, e.g. milk, cheese
Gluten, e.g. bread, pasta, crackers
Sugar, e.g. sweets, chocolate, cakes
Junk food, e.g. burgers, sausages, pizza
Chicken
Fish
Red meat
Vegetables
Fruit
Nuts
Other:
What exercise do you do regularly?
Walking
Jogging
Running
Weight lifting
Home workout
Cycling
Swimming
Pilates
Yoga
Other:
What stretching do you do regularly?
A few minutes once daily
A few minutes twice or three times daily
Physiotherapy exercises
Yoga
Pilates
Don't stretch
Other:
What meditation do you do regularly?
Guided meditation (mobile app / YouTube)
Meditate alone
Dynamic meditation (e.g. while walking)
Yoga
Prayer
Don't meditate
Don't know what meditation is
Other:
What vitamins / supplements do you take regularly?
Multivitamin
Vitamin D
Vitamin B
Vitamin C
Vitamin E
Magnesium
Zinc
Omega 3
Priobiotics
CBD oil
Other:
What type of medications do you take regularly?
Tricyclic antidepressants, e.g. amitriptyline
SSRIs, e.g. sertraline
SNRIs, e.g. venlafaxine
Anticonvulsants, e.g. pregabalin
Opioids, e.g tramadol
NSAIDs, e.g. diclofenac
Other painkillers, e.g. paracetamol
Prescribed medical cannabis
Other:
List your regular medications
Your answer
Do you use any of the following substances regularly?
Cigarettes / tobacco
Alcohol
Coffee
Opiates
Psychedelics
Other:
Further comments / notes / information
Your answer
Would you like advice on how to manage your pain?
General advice by email
Advice over the phone
Advice at The Pain Clinic
Video consultation with doctor
Clinic consultation with doctor
No advice needed
Other:
Clear selection
Do you give your consent to use this information anonymously for research purposes?
Yes
No
Other:
Clear selection
Send me a copy of my responses.
Submit
Page 1 of 1
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
