Patient Follow-Up Form

First Name Middle Name Last Name

DaysMonthsWeeksYears

ProcedureMedication RefillBothNeither

I have no pain any longer, I feel great!I am much better.I am better, but not great.I am sort of better, but not much.I am no better at all, no relief at all.

I am back to doing everything I want to do and even more. I am back to work.I can do a lot of stuff that I couldn't do when the pain was so intense, but would like to do more.I can do more stuff, but the pain still stops me from doing some things.I feel I can do more, but the pain is still very much limiting what I can or cannot do.I still can't do anything I want to do or go to work because the pain is still too severe.

Weight/Appetite ChangesFever/ChillsDisturbed Sleeping Habits

Chest PainHeart MurmurSkipped Beats

Easy BruisabilityDifficulty In Dotting The Blood

Eye InfectionsBlurred VisionDouble VisionBlindness

Bladder IncontinenceDifficulty Urinating

DepressionMood SwingsAnxiety

LacerationsAbrasionsPustulesNodules

Could you please complete this questionnaire? It is designed to give us information as to how your pain has affected your ability to manage in every day life.

Please answer every section. Mark one box only in each section that most closely describes yout today.

(0) I have no pain at the moment(1) The pain is very mild at the moment(2) The pain is moderate at the moment(3) The pain is fairly severe at the moment(4) The pain is severe at the moment(5) The pain is the worst imaginable at the moment

(0) I can look after myself normally without extra pain(1) I can look after myself but it is very painful(2) It is painful to look after myself and I am slow(3) I need some help but manage most of my personal care(4) I need help everyday in most aspects of my care(5) I do not get dressed, wash with difficulty and stay in bed

(0) I can lift heavy weights without extra pain(1) I can lift heavy weights but it gives me extra pain(2) Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned; for instance, on the table(3) Pain prevents me from lifting heavy objects but I can manage light to medium weights if they are conveniently positioned; for instance, on the table(4) I can only lift light weights(5) I am in bed most of the time and have to crawl to the toilet

(0) Pain does not prevent me from walking any distance(1) Pain prevents me from walking more than 1 mile(2) Pain prevents me from walking more than 1/4 of a mile(3) Pain prevents me from walking more than 100 yards(4) I can only walk using a stick or crutches(5) I am in bed most of the time and have to crawl to the toilet

(0) I can sit in any chair for as long as I like(1) I can sit in my favorite chair for as along as I like(2) Pain prevents me from sitting more than 1 hour(3) Pain prevents me from sitting more than half an hour(4) Pain prevents me from sitting more than 10 minutes(5) Pain prevents me from sitting at all

(0) I can stand as long as I want without extra pain(1) I can stand as long as I want but it gives me extra pain(2) Pain prevents me from standing more than 1 hour(3) Pain prevents me from standing more than a half an hour(4) Pain prevents me from standing more than 10 minutes(5) Pain prevents me from standing at all

(0) My sleep is never disturbed by pain(1) My sleep is occasionally disturbed by pain(2) Because of pain, I have less than 6 hours of sleep(3) Because of pain, I have less than 4 hours of sleep(4) Because of pain, I have less than 2 hours of sleep(5) Pain prevents me from sleeping at all

(0) My sex life is normal and causes me no extra pain(1) My sex life is normal but causes some extra pain(2) My sex life is nearly normal but is very painful(3) My sex life is severely restricted by pain(4) My sex life is nearly absent because of pain(5) Pain prevents any sex life at all

(0) My social life is normal and causes me no extra pain(1) My social life is normal but increases the degree of my pain(2) Pain has no significant effect on my social life apart from limiting my more energetic interests (i.e. sports, etc.)(3) Pain has restricted my social life and I do not go out(4) Pain has restricted social life to my house(5) I have no social life because of pain

(0) I can travel anywhere without pain(1) I can travel anywhere but it gives me extra pain(2) Pain is bad but I manage journeys over 2 hours(3) Pain restricts me to short journeys of less than 1 hour(4) Pain restricts me to short journeys less than 30 minutes(5) Pain prevents me from traveling except to receive treatment

Patient Follow-Up Form

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