Questionnaire for WorkCover Patients
Please select your Pain Matrix branch
Pain Matrix Geelong
Pain Matrix Eastern
Name:
Referring Doctor:
Claim Number:
Employer:
Type of Work:
Insurance Company:
Current Case Worker:
Case Worker Phone:
Case Worker email:
example@example.com
Date of Accident:
/
Month
/
Day
Year
Date
Details of Accident:
Injury Diagnosis:
Other Details (such as any aggravation or recurrence of a previous injury or a degenerative component):
How does the pain affect your ability to do the following?
1: Standing:
2: Sitting:
3: Walking:
4. Bending:
5: Lifting:
6. Squatting:
How does the pain affect your ability to enjoy family time and hobbies?
What physical tasks does your usual job entail?
Have you been prescribed any of the following medications? (select all that apply)
Pregabalin (e.g. Lyrica)
Gabapentin (e.g. Neurontin, Gabatine, Nupentin, APO Gabapentin)
Tramadol (e.g. GA Tramadol, Lodam, Zydol, Tramal)
Duloxetine (e.g. Cymbalta, Andepra, Coperin, Drulox)
Nortriptyline (e.g. Allegron)
Paracetamol & Codeine Phosphate (e.g. Panadeine Forte, Prodeine Forte, Codapane Forte)
Oxycodone (e.g. Oxycontin)
Morphine (e.g. MS Contin, Momex, Apotex Morphine)
Buprenorphine (e.g. Norspan)
Fentanyl (e.g.Fentanyl Sandoz, Actiq, Denpax, Dutran, Fenpatch)
Meloxicam (e.g.Mobic, Melox, Meloxicam Sandoz, Movalis)
Ibuprofen (e.g.Nurofen, Rafen, Brufen, Herron Blue, Advil)
Celecoxib (e.g. Celebrex)
Diclofenac (e.g.Voltaren)
Naproxen (e.g. Naprosyn, Proxen)
Are there any other treatments that you have undertaken for your pain?
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