Pain History Questionnaire

1
Please enter the identification code from your SMS/email* This field is required.
2
First let's find out a little about the pain itself.
3
Where in your body is your main pain?* This field is required.Please select the region which you feel your main pain originates
Please Select
Please Select
I'm sore all over
Head
Neck
Chest
Abdomen
Pelvis
Upper back
Lower back
Hips/Buttock
Upper leg
Knee
Lower leg
Feet
Shoulder
Upper arm
Elbow
Forearm/wrists
Hands
Location
Please Select
Please Select
Right
Left
Both sides
N/A
Side
4
Does the pain radiate/travel to another part of your body?* This field is required.
YESNO
5
Where where does the pain radiate?* This field is required.You can select more than one region
Head
Neck
Chest
Abdomen
Upper back
Lower back
Hips/Buttock
Upper leg
Knee
Lower leg
Feet
Shoulder
Upper arm
Elbow
Forearm/wrists
Hands
Location
Please Select
Please Select
Right
Left
Both sides
N/A
Side
6
Do you also have pain in other parts of your body?* This field is required.
YESNO
7
Where else do you have pain?* This field is required.Pick all that apply
Head
Neck
Chest
Abdomen
Upper back
Lower back
Shoulder
Arm/hand
Hips/buttocks
Knees
Legs
Feet
8
Number pain areas
9
How long has your main pain been present?* This field is required.
Less than 3 months
3 to 12 months
12 months to 2 years
2 to 5 years
More than 5 years
10
How did your main pain begin?* This field is required.
No obvious cause or event/slow onset
Injury
After Surgery
Cancer
Medical condition other than cancer
Other
11
Where did the injury happen?* This field is required.
Home
Work/School
Social event / Sport
Motor vehicle accident
Other
12
Was it associated with a worker's compensation claim?* This field is required.
YESNO
13
Was it associated with a ICWA / MVIT (insurance) claim?* This field is required.MVIT is the medical insurance claim associated with motor vehicle accidents
YESNO
14
Has this claim been finalised?* This field is required.
YESNO
15
What type of cancer?* This field is required.
16
What medical condition?* This field is required.
17
What type of surgery?* This field is required.
18
Please rate the intensity of your pain at its WORST over the last week* This field is required.0 = No pain. 10 = as bad as you can imagine
0
1
2
3
4
5
6
7
8
9
10
19
Please rate the intensity of your pain at its BEST over the last week* This field is required.0 = No pain. 10 = as bad as you can imagine
0
1
2
3
4
5
6
7
8
9
10
20
Please rate the AVERAGE intensity of your pain over the last week* This field is required.0 = No pain. 10 = as bad as you can imagine
0
1
2
3
4
5
6
7
8
9
10
21
Please rate the intensity of your pain right NOW* This field is required.0 = No pain. 10 = as bad as you can imagine
0
1
2
3
4
5
6
7
8
9
10
22
BPI Pain average
23
During the last week, how much has your pain interfered with your general activity?* This field is required.0 = does not interfere. 10 = completely interferes.
0
1
2
3
4
5
6
7
8
9
10
24
During the last week, how much has your pain interfered with your mood?* This field is required.0 = does not interfere. 10 = completely interferes.
0
1
2
3
4
5
6
7
8
9
10
25
During the last week, how much has your pain interfered with your walking ability?* This field is required.0 = does not interfere. 10 = completely interferes.
0
1
2
3
4
5
6
7
8
9
10
26
During the last week, how much has your pain interfered with your normal work (both outside the home and house work)?* This field is required.0 = does not interfere. 10 = completely interferes.
0
1
2
3
4
5
6
7
8
9
10
27
During the last week, how much has your pain interfered with your relations with other people?* This field is required.0 = does not interfere. 10 = completely interferes.
0
1
2
3
4
5
6
7
8
9
10
28
During the last week, how much has your pain interfered with your sleep?* This field is required.0 = does not interfere. 10 = completely interferes.
0
1
2
3
4
5
6
7
8
9
10
29
During the last week, how much has your pain interfered with your enjoyment of life?* This field is required.0 = does not interfere. 10 = completely interferes.
0
1
2
3
4
5
6
7
8
9
10
30
BPI Interference average
31
Which best describes the course of your pain?* This field is required.
Persisent pain with slight fluctuations
Persistent pain with attacks
Pain attacks without pain between them
Pain attacks with varying pain between them
32
Do you suffer from a burning sensation (eg. stinging nettles) in the area of your pain?* This field is required.
Never
Hardly noticed
Slightly
Moderately
Strongly
Very Strongly
33
Do you have a tingling or prickling sensation (like crawling ants or electrical tingling) in the area of your pain?* This field is required.
Never
Hardly noticed
Slightly
Moderately
Strongly
Very Strongly
34
Is light touching (eg clothing or a blanket) painful in the area of your pain?* This field is required.
Never
Hardly noticed
Slightly
Moderately
Strongly
Very Strongly
35
Do you have sudden pain attacks, like electric shocks in the area of your pain?* This field is required.
Never
Hardly noticed
Slightly
Moderately
Strongly
Very Strongly
36
Is hot or cold (ie bath water) occasionally painful in the area of your pain?* This field is required.
Never
Hardly noticed
Slightly
Moderately
Strongly
Very Strongly
37
Do you suffer from a sensation of numbness in the area of your pain?* This field is required.
Never
Hardly noticed
Slightly
Moderately
Strongly
Very Strongly
38
Does slight pressure (eg with a finger) in this area trigger pain?* This field is required.
Never
Hardly noticed
Slightly
Moderately
Strongly
Very Strongly
39
Pain Detect Score
40
Pain Detect Classification
41
I feel tired and unrefreshed when I wake from sleeping.* This field is required.
Never
Rarely
Sometimes
Often
Always
42
My muscles feel stiff and achy.* This field is required.
Never
Rarely
Sometimes
Often
Always
43
I have anxiety attacks.* This field is required.
Never
Rarely
Sometimes
Often
Always
44
I grind or clench my teeth* This field is required.
Never
Rarely
Sometimes
Often
Always
45
I have problems with diarrhea and/or constipation* This field is required.
Never
Rarely
Sometimes
Often
Always
46
I need help in performing my daily activities* This field is required.
Never
Rarely
Sometimes
Often
Always
47
I am sensitive to bright lights* This field is required.
Never
Rarely
Sometimes
Often
Always
48
I get tired very easily when I am physically active* This field is required.
Never
Rarely
Sometimes
Often
Always
49
I feel pain all over my body* This field is required.
Never
Rarely
Sometimes
Often
Always
50
I have headaches* This field is required.
Never
Rarely
Sometimes
Often
Always
51
I feel discomfort in my bladder and/or burning when I urinate* This field is required.
Never
Rarely
Sometimes
Often
Always
52
I do not sleep well* This field is required.
Never
Rarely
Sometimes
Often
Always
53
I have difficulty concentrating* This field is required.
Never
Rarely
Sometimes
Often
Always
54
I have skin problems such as dryness, itchiness or rashes* This field is required.
Never
Rarely
Sometimes
Often
Always
55
Stress makes my physical symptoms worse* This field is required.
Never
Rarely
Sometimes
Often
Always
56
I feel sad or depressed* This field is required.
Never
Rarely
Sometimes
Often
Always
57
I have low energy* This field is required.
Never
Rarely
Sometimes
Often
Always
58
I have muscle tension in my neck and shoulders* This field is required.
Never
Rarely
Sometimes
Often
Always
59
I have pain in my jaw* This field is required.
Never
Rarely
Sometimes
Often
Always
60
Certain smells, such as perfumes, make me feel dizzy and nauseated* This field is required.
Never
Rarely
Sometimes
Often
Always
61
I have to urinate frequently* This field is required.
Never
Rarely
Sometimes
Often
Always
62
My legs feel uncomfortable and restless when I am trying to sleep at night* This field is required.
Never
Rarely
Sometimes
Often
Always
63
I have difficulty remembering things* This field is required.
Never
Rarely
Sometimes
Often
Always
64
I suffered trauma as a child* This field is required.
Never
Rarely
Sometimes
Often
Always
65
I have pain in my pelvic area* This field is required.
Never
Rarely
Sometimes
Often
Always
66
Central Sensitisation Inventory (CSI) Score
67
Central Sensitisation Inventory (CSI) Category
68
Now a bit about how you manage your pain.
69
Have you previously seen a Pain Medicine Specialist?* This field is required.
YESNO
70
Who?
71
What non-medication treatments do you currently use to manage your pain?* This field is required.
Heat packs
Cold/ice
Physiotherapy
Chiropractic/Osteopathy
Massage
Acupuncture/Dry needling
Relaxation/Meditation/Mindfulness
Hydrotherapy/Swimming
Stretches/strengthening exercises
Exercise
TENS
Nil
Other
72
Name of Physiotherapist/Practice?
73
Name of Chiropractor/Osteopath or their practice?
74
Who performs the acupuncture/ dry needling?
75
How did you learn mindfulness/meditation/relaxation?* This field is required.
Clinical psychologist
GP
Self taught/ book/ internet
Other
76
How did you learn your stretches/strengthening exercises?* This field is required.
Physiotherapist
GP
Self taught/ book/ internet
Other
77
What exercise do you do?* This field is required.
78
What non-medication treatments have you previously tried to manage your pain?* This field is required.No longer use
Surgery
Injections/Procedures
Physiotherapy
Chiropractic/Osteopathy
Massage
Acupuncture/Dry needling
Relaxation/Meditation/Mindfulness
Hydrotherapy/Swimming
Stretches/strengthening exercises
Exercise
TENS
Nil
Other
79
What type of surgery?* This field is required.
80
Name of surgeon/s?
81
What injections/procedures have you previously had? * This field is required.
82
Who performed the procedures?* This field is required.
83
When you saw a physiotherapist, what treatments did they provide?* This field is required.
Manual therapy/massage
Dry needling
Ultrasound
TENS
Taping
Exercise/Stretching program
Other
84
Was the mindfulness/relaxation taught by a clinical psychologist?
YESNO
85
Have you previously had imaging (Xray, CT, MRIs) for your pain?* This field is required.
YESNO
86
Where (which imaging companies)?* This field is required.
SKG
Perth Radiology Clinic (PRC)
Envision
Apex (prev Global Diagnostics)
Western Radiology
I-MED (previously InSight)
WA Public hospital
I can't remember
Other
87
What pain medications have you previously tried, but are no longer using (including non-prescription and herbal)? Try to remember as many as possible * This field is required.I already have a list of your current medications from the past medical history questionnaire
88
Now a bit about the impact of your pain on you as a person
89
Are you currently employed (working for pay)?* This field is required.
YESNO
90
What is your job?* This field is required.
91
Hours of work* This field is required.
Full time
Part time - limited by pain
Part time - unrelated to pain
92
During the past seven days, how many hours did you miss from work because of problems associated with your pain?* This field is required.
93
During the past seven days, how many hours did you actually work?* This field is required.
94
Reason for unemployment?* This field is required.
Not working by choice (retired, homemaker, student)
Unable to work due to pain
Unable to work due to condition other than pain
Seeking employment
95
Do you require assistance with domestic activities of daily living (shopping, cooking, cleaning) because of your pain?* This field is required.
YESNO
96
Do you require assistance with personal activities of daily living (dressing, showering, toileting) because of your pain?* This field is required.
YESNO
97
Who do you receive assistance from?* This field is required.
Family members
Friends
Service provider (ie SilverChain)
Paid carer
Other
98
Are you on a disability support pension?* This field is required.
YESNO
99
Are you on the NDIS?* This field is required.
YESNO
100
Please rate the following statements as they applied to you over the last week.
101
I found it hard to wind down* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
102
I was aware of dryness of my mouth* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
103
I couldn't seem to experience any positive feeling at all* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
104
I experienced breathing difficulty (eg. excessively rapid breathing, breathlessness in the absence of physical exertion)* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
105
I found it difficult to work up the initiative to do things* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
106
I tended to over react to situations* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
107
I experienced trembling (eg. in the hands)* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
108
I felt that I was using a lot of nervous energy* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
109
I was worried about situations in which I might panic and make a fool of myself* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
110
I felt I had nothing to look forward to* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
111
I found myself getting agitated* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
112
I found it difficult to relax* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
113
I felt down-hearted and blue* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
114
I was intolerant of anything that kept me from getting on with what I was doing* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
115
I felt I was close to panic* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
116
I was unable to become enthusiastic about anything* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
117
I felt I wasn't worth much as a person* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
118
I felt that I was rather touchy* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
119
I was aware of the action of my heart in the absence of physical exertion (eg. sense of heart rate increase, heart missing a beat)* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
120
I felt scared without any good reason* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
121
I felt life was meaningless* This field is required.
Not at all
Some of the time
A good part of the time
Most of the time
122
DASS Depression
123
DASS Depression Severity
124
DASS Anxiety
125
DASS Anxiety Severity
126
DASS Stress
127
DASS Stress Severity
128
DASS Total Score
129
Please rate how confident you are that you can do the following things at present despite pain. 0 = Not confident at all, 6 = Completely confident
130
I can enjoy things, despite pain* This field is required.0 = Not at all confident, 6 = Completely confident
0
1
2
3
4
5
6
131
I can do most of the household chores (eg. tidying up, washing dishes, etc) despite the pain* This field is required.0 = Not at all confident, 6 = Completely confident
0
1
2
3
4
5
6
132
I can socialise with my friends or family members as often as I used to do, despite the pain* This field is required.0 = Not at all confident, 6 = Completely confident
0
1
2
3
4
5
6
133
I can cope with my pain in most situations* This field is required.0 = Not at all confident, 6 = Completely confident
0
1
2
3
4
5
6
134
I can do some form of work, despite the pain ("work" includes housework, paid and unpaid work)* This field is required.0 = Not at all confident, 6 = Completely confident
0
1
2
3
4
5
6
135
I can still do many of the things I enjoy doing, such as hobbies or leisure activities, despite the pain* This field is required.0 = Not at all confident, 6 = Completely confident
0
1
2
3
4
5
6
136
I can cope with my pain without medication* This field is required.0 = Not at all confident, 6 = Completely confident
0
1
2
3
4
5
6
137
I can still accomplish most of my goals in life, despite the pain* This field is required.0 = Not at all confident, 6 = Completely confident
0
1
2
3
4
5
6
138
I can live a normal lifestyle, despite the pain* This field is required.0 = Not at all confident, 6 = Completely confident
0
1
2
3
4
5
6
139
I can gradually become more active, despite the pain* This field is required.0 = Not at all confident, 6 = Completely confident
0
1
2
3
4
5
6
140
PSEQ total
141
PSEQ Severity
142
Everyone experiences pain at some point in their lives, through a variety of situations. Pain triggers different emotions and thoughts in different indiviuals.

We are interested in the types of thoughts and feelings you have when you are in pain. Please rate the degree to which the following statements relate to the thoughts and feelings you have when you are in pain.
143
I worry all the time about whether the pain will end* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
144
I feel I can't go on* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
145
It's terrible and I think it's never going to get any better* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
146
It's awful and I feel that it overwhelms me* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
147
I feel I can't stand it anymore* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
148
I become afraid that the pain may get worse* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
149
I keep thinking of other painful experiences* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
150
I anxiously want the pain to go away* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
151
I can't seem to keep it out of my mind* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
152
I keep thinking about how much it hurts* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
153
I keep thinking about how badly I want the pain to stop* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
154
There's nothing I can do to reduce the intensity of the pain* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
155
I wonder whether something serious may happen* This field is required.
Not at all
To a slight degree
To a moderate degree
To a great degree
All the time
156
PCS total
157
PCS severity category
158
PCS Rumination
159
PCS Magnification
160
PCS Helplessness
Should be Empty: