Pain and Medical Questionnaire

STEP 1 - Patient Details

Your Name(Required)

Prefix First Last

Date of Birth(Required)

Day

Month

Year

Height(Required)

Weight(Required)

BMI (if known)

Gender(Required)

Male

Female

Contact Number(Required)

Do you have a referral from my Doctor(Required)

STEP 2 - The pain you are experiencing

Tell us why you’re coming to see us at Interventus.(Required)

Indicate on the diagram below exactly where you are experiencing pain.

Clear

Hold your mouse button down and move it around to draw.

Indicate on the diagram below exactly where you are experiencing pain.

Clear

Hold your mouse button down and move it around to draw.

In the last week, what were your pain levels on a scale of 0-10? (0 = no pain, 10 = highest level of pain)*

Highest level of pain:(Required)

Lowest level of pain:(Required)

Average level of pain:(Required)

Click which word/s describe your pain*(Required)

Shooting

Aching

Burning

Electric Shock

Pricking

Tingling

Pins & Needles

Numbness

Other

Other (if not mentioned above)

Are there any activities or movements that make your pain worse, such as going up stairs, bending or twisting, walking or getting out of bed?(Required)

Is there anything that reduces your pain?(Required)

When you’re experiencing your pain, do you also experience any of the following? (Tick all that apply)(Required)

Changes in bladder control

Numbness

Weakness

None of the above

When did you first experience your pain?(Required)

Do you know why you are experiencing pain? For example, is it following an accident or a fall, or has it developed over time?(Required)

Tell us about the affect your pain is having on your day-to-day life. In the last week, to what extent has your pain impacted or interfered with the following on a scale of 1-10? (0 = no interference, 10 = complete interference)

Your sleep(Required)

Your ability to work or maintain employment(Required)

Your relationships(Required)

Your ability to look after yourself(Required)

Your mobility(Required)

Your ability to participate in leisure activities(Required)

Your moods and emotions(Required)

Your sexual activity(Required)

Have you previously tried any of the following pain treatments? (Tick all that apply)(Required)

Anti-inflammatories

Cortisone Injections

Cymbalta or Duloxetine

Endep or Allegron

Facet Joint Injections

Ketamine infusions

Lignocaine infusions

Lyrica or Gabapentin

Medicinal cannabis

Nerve Blocks

Opioids or Narcotics

Orphenadrine (Norflex)

Pain Management Program

Pain Pumps

Paracetamol

Physiotherapy

Psychology

Radiofrequency Treatments

Spinal Cord Stimulators

TENS

Tramadol or Palexia

Other

Other (if not listed above)

Have you had any medical imaging in relation to the pain?(Required)

Yes

If yes:

What type of scan?

Where did you have this scan?

Click on the + if you need to add more lines

STEP 3 - Your medical history and medications

Have you ever had any of the following medical or mental health conditions? (Please tick all that apply)(Required)

Abnormal heart rhythm

Anxiety

Arthritis

Asthma/bronchitis

Bleeding disorders

Blood Thinning Treatment

Cancer

Depression

Diabetes

Drug or Alcohol Abuse

Epilepsy

Fibromyalgia

Heart attack or angina

Heart failure

High blood pressure

HIV / AIDS

Irritable bowel syndrome

Kidney disease

Liver disease

Migraine

Multiple sclerosis

Painful menstrual periods

PTSD

Recent weight loss

Sleep apnoea

Stroke or TIAs

Thyroid condition

No medical or mental health history

Other medical condition

Other mental health condition

Other - Not listed above

If you answered yes to any of the above, please provide more information below.

Condition

Details

Click on the + if you need to add more lines

Have you had any operations/procedures?(Required)

Yes

If yes:

What was the operation or procedure?

When was it performed?

What hospital or clinic was it performed at?

Click on the + to add more lines

Have you ever been hospitalized for a mental health condition?(Required)

If yes, how long ago did this take place?

Do you ever experience suicidal thoughts?(Required)

If you answered yes, please seek help immediately by calling your doctor or Lifeline (13 11 14), or visit www.suicidecallbackservice.org.au. For urgent support, call 000.

Do you feel safe from self-harm today?(Required)

If you answered yes, please seek help immediately by calling your doctor or Lifeline (13 11 14), or visit www.suicidecallbackservice.org.au. For urgent support, call 000.

Are you currently taking any medications?(Required)

Yes

If yes, please list all of your current medications (including those not taken for pain):(Required)

Medication name

Medication strength

Number taken & when taken

Press the + to add more lines

Do you have any allergies?(Required)

Yes

If yes, what are you allergic to and what is the reaction?

STEP 4 - Your general lifestyle

Do you smoke?(Required)

If you’re a current smoker, how many do you have per day?

Do you drink alcohol?(Required)

If yes, how many standard drinks do you have per day?

Do you have a personal or family history of alcohol or drug misuse?(Required)

If yes, please provide further details:

Are you currently employed?(Required)

Yes, full time

Yes, part time

No, I don’t work

What is your occupation? Or if you’re not working now, what was your previous occupation?(Required)

Who do you live with?(Required)

(Please include all family members, housemates, pets etc)

How did you hear about Interventus Pain Management?

Do you have any additional comments?

I acknowledge that:(Required)

I have read and accept the Interventus Pain Specialists Privacy Policy

I have read and accept the Interventus Pain Specialists Terms of Use

Name

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

It’s our mission to help our patients achieve freedom from pain