Pain Questionnaire

Soon you have an appointment scheduled at the Pain Clinic in Amstelland Hospital. We request that all our new patients complete the digital pain questionnaire below prior to their appointment with the pain specialist. The completion of the pain questionnaire ensures that the pain specialist has access to your medical background before the appointment and gives the pain specialist an overview of your situation. This saves valuable time and enables the clinic to work efficiently.

We ask you to bring the following:

An up to date list of all your medications which can be obtained at your pharmacy.
Referal letter.
Hospital registration card.

To make or change appointments, please contact the Pain Clinic Monday - Friday from 9:00-12:00 and from 13:00-16:00.

Kind regards,

Amstelland Outpatient Pain Clinic
020 – 755 7010
[email protected]

Personal details

Name:

Date of birth:

What is your e-mail address?

General information

Do you smoke?

Do you drink alcohol?

Do you use drugs?

Do you have any allergies?

1101. Are you a man or a woman?

Man

Woman

1102. What is your age (in years)?

Pain symptoms

1103. For which pain symptoms were you referred?

Headache

Neck, shoulder or upper back pain (with or without radiation to one or both arms)

Pain in one or both elbows, wrists or hands

Pain in the lower back (with or without radiation to one or both legs)

Pain in one or both hips or knees

Pain in one or both ankles or feet

Pain in the chest or stomach

Other

Namely:

How long have you had this pain?

Less than a year

A year or longer

Namely ... months

Namely ... years

Namely:

Work situation

Since:

Namely:

Only answer question 1401 if you're completing this questionnaire for the second time

GPE

1401. Since beginning the treatment, to what degree have you recovered from your symptoms? (tick one answer). Degree of recovery:

SF-12v2 Health
The following question has to do with your impression of your heath. You can use this information to monitor how you feel and how well you are able to perform your normal activities.

The following questions relate to your activities on an average day. Does your health currently limit your ability to do these activities? If so, to what degree?

1502. Moderate exertion, such as moving a table, vacuuming, swimming or cycling

Yes, severely limited

Yes, slightly limited

No, not limited at all

1503. Walking up some steps

Yes, severely limited

Yes, slightly limited

No, not limited at all

Within the past 4 weeks, how often have you experienced any of the following problems with your work or other daily activities due to your physical health?

Within the past 4 weeks, how often have you experienced any of the following problems in your work or other daily activities due to emotional issues (e.g. feeling depressed or anxious)?

1508. Within the past 4 weeks, to what extent has pain bothered you during your normal work (both work outside the home and household chores?

These questions are about how you feel and how things were for you over the last four weeks. For every question, please give the answer that best describes how you felt. Over the past 4 weeks, how often ...

1512. Within the past 4 weeks, how often have problems with your physical health or emotional issues hindered your social activities (e.g. visiting friends or family, etc.)?

NRS
Please indicate how strong the pain is. You can do this by entering the number that best matches the level of pain that you experience. 0 means 'no pain at all' and 10 means 'unbearable pain'. If you only have a slight amount of pain, choose a lower number. If you have a lot of pain, choose a higher number. You can only enter one number at a time.

Read the questions carefully, because there are multiple questions.

1601. How intense is your pain currently?

1602. On average, how intense was your pain over the past week?

1603. How intense is your pain at its weakest?

1604. How strong is your pain at its worst?

BPI
Enter the number that best describes how the pain has hindered you during the past 24 hours:
(0 stands for no obstacle and 10 for total obstruction)

1701. General activity

1702. Mood

1703. Ability to walk

1704. Normal work (this includes both work outside the home and household chores)

1705. Relationships with others

1706. Sleep

1707. Enjoyment of life

Only answer questions 1801-1810 if you have lower back complaints

OLBPDQ
The following 10 questions are designed to provide us with information about how your back (or leg) complaints affect your ability to manage your daily life. Please answer all of the questions. If a section does not apply to you, such as the use of painkillers or questions about your sex life, you can skip that section. For every question, choose the option that best suits you today.

1801. Section 1 - Pain severity

I can tolerate the pain without having to use painkillers.

The pain is bad, but I don't have to use painkillers.

Painkillers completely eliminate the pain.

Painkillers help moderately against the pain.

Painkillers only help a little bit.

Painkillers do not help, and I don't use them.

1802. Section 2 - Self-care (washing and dressing)

I can wash and dress myself normally without extra pain.

I can wash and dress myself normally, but I have extra pain.

It hurts when I wash and dress myself, that's why I'm slow and careful with these activities.

I need some help, but I can do most of the washing and dressing myself.

I need help every day with most aspects of my self-care.

I don't dress myself

I struggle to wash and I stay in bed.

1803. Section 3 - Lifting

I can lift a heavy object without extra pain.

I can lift a heavy object, but it causes extra pain.

I cannot lift heavy objects from the ground due to the pain. But I can manage when they are in a convenient place, such as on the table.

I cannot lift heavy objects due to the pain. But I can lift lightweight to medium-heavy objects if they are in a handy place.

I can only lift very light objects.

I cannot lift or carry anything.

1804. Section 4 - Walking

Pain does not prevent me from walking far distances.

Pain prevents me from walking further than 2 kilometers.

Pain prevents me from walking further than 1 kilometer.

Pain prevents me from walking further than 500 meters.

I can only walk with the aid of a cane or crutches.

I spend most of my time in bed and have to crawl to the toilet.

1805. Section 5 - Sitting

I can sit in any chair for as long as I want.

I can only sit in my favorite chair for as long as I want.

I cannot sit for longer than an hour because of the pain.

I cannot sit for longer than half an hour because of the pain.

I cannot sit for longer than 10 minutes because of the pain.

I cannot sit at all because of the pain.

1806. Section 6 - Standing up

I can stand for as long as I want, without experiencing additional pain.

I can stand for as long as I want, but it causes more pain.

I cannot stand for longer than an hour, due to the pain.

I cannot sit for longer than 30 minutes, due to the pain.

I cannot sit for longer than 10 minutes, due to the pain.

I cannot stay standing, due to the pain.

1807. Section 7 - Sleeping

Despite the pain, I sleep well.

I can only sleep well if I take tablets.

Even if I take tablets, I sleep less than 6 hours a night.

Even if I take tablets, I sleep less than 4 hours a night.

Even if I take tablets, I sleep less than 2 hours a night.

I do not sleep at all, due to the pain.

1808. Section 8 - Sex life

My sex life is normal and does not cause me any extra pain.

My sex life is normal, but it does cause me extra pain.

My sex life is almost normal, but it's very painful.

My sex life is severely limited, due to the pain.

My sex life is virtually nonexistent, due to the pain.

Because of the pain, I no longer have a sex life.

1809. Section 9 - Social life

My social life is normal and does not cause me any extra pain.

My social life is normal, but it does cause me extra pain.

With the exception of more strenuous activities, such as dancing, etc., the pain does not significantly impact my social life.

The pain has restricted my social life, and I leave home less often.

Because of the pain, my social life is limited to my home.

I don't have a social life, due to the pain.

1810. Section 10 - Travel/Transport

I can travel everywhere without extra pain.

I can travel anywhere, but I do have extra pain.

While the pain is bad, I can still go on trips lasting longer than 2 hours. I cannot travel for longer than an hour, due to the pain.

Because of the pain, I can only make short, necessary trips lasting less than 30 minutes.

Because of the pain, I only leave my home to see a doctor or to go to the hospital.

Only answer questions 1901-1910 if you have neck complaints

NDI
The following 10 questions are designed to provide us with information about how your back (or leg) complaints affect your ability to manage your daily life. Please answer all of the questions. For each question, choose the option that best suits you today.

1901. Pain

I don't have pain at the moment.

I have a bit of pain at the moment.

I have moderate pain at the moment.

I currently have very intense pain.

I currently have very severe pain.

I currently have the worst imaginable pain.

1902. Personal care (washing, dressing and undressing)

I can take good care of myself without my pain increasing.

I can take good care of myself, although doing so increases my pain.

It is painful to take care of myself, and I have to do these activities slowly and carefully.

I can take good care of myself, but I often require some help.

I normally require daily assistance to take care of myself.

I cannot dress myself, it is difficult to wash myself and I remain in bed.

1903. Lifting

I can lift something heavy without my pain increasing.

I can lift something heavy, but doing so increases my pain.

The pain prevents me from lifting something heavy from the ground, but I can lift that same weight if the object is on a higher level (e.g. on a table).

The pain prevents me from lifting heavy items, but I manage to lift light- to medium-weight items if they are placed in a convenient location.

I can only lift very lightweight objects.

I cannot lift or carry anything.

1904. Reading

I can read as much as I want without any pain in my neck.

I can read as much as I want with a slight pain in my neck.

I can read as much as I want with moderate pain in my neck.

I cannot read as much as I would like because of the moderate pain in my neck.

I can hardly read due to severe pain in my neck.

I can no longer read at all.

1905. Headache

I do not have a headache.

I occasionally have a slight headache.

I occasionally have a moderate headache.

I often have moderate headaches.

I often have severe headaches.

I almost always have a headache.

1906. Concentration

I can concentrate well without difficulty whenever I want.

I can concentrate well when I want to, but it takes some effort.

It clearly takes effort for me to concentrate when I want to.

It takes a great deal of effort for me to concentrate when I want to.

It takes an incredible effort on my part to concentrate when I want to.

I cannot concentrate at all.

1907. Work

I can do as much work as I want.

I can only do my normal work, but no more than this.

I can do most of my standard work, but no more than this.

I cannot do my standard work.

I can hardly do any work anymore.

I no longer can work anymore.

1908. Driving

I can drive without any neck pain.

I can drive for as long as I want with some slight pain in my neck.

I can drive for as long as I want with moderate pain in my neck.

I cannot drive as much as I would like to due to the moderate pain in my neck.

I can hardly drive due to the severe pain in my neck.

I cannot drive at all anymore.

1909. Sleeping

I have no trouble sleeping.

My sleep is very slightly disturbed (lying awake for less than 1 hour).

My sleep is slightly disturbed (lying awake for 1 to 2 hours).

My sleep is moderately disturbed (lying awake for 2 to 3 hours).

My sleep is severely disturbed (lying awake for 3 to 5 hours).

My sleep is totally disturbed (lying awake for 5 to 7 hours).

1910. Free time

I can participate in any activity without any pain in my neck.

I can participate in any activity with only some pain in my neck.

Due to the pain in my neck, I can participate in most, but not all, of my usual activities.

Due to the pain in my neck, I can participate in some of my usual activities.

Due to the pain in my neck, I can hardly participate in any activities.

I no longer can participate in any activity.

Only answer questions 2001-2014 if you're completing this questionnaire for the first time

HADS
It is well known that emotions play an important role in most diseases. The following questions are a tool to help us determine how you're feeling. Read each question and select the answer that best describes how you felt last week. Do not think too long about your answer. Your first reaction to each question is probably more reliable than a long-considered answer.

2001. I feel stressed:

Almost always

Often

Sometimes

Never

2002. I still enjoy doing the things that I normally like:

Certainly as much

Slightly less

Clearly less

Hardly at all anymore

2003. I feel anxious, like something terrible is going to happen:

Very certainly

Definitely

A little

Not at all

2004. I can laugh and see things from a cheerful perspective:

As much as usual

Somewhat less now

Clearly less now

Not at all any more

2005. I'm worried:

Very often

Often

Not that often

Rarely

2006. I feel cheerful:

Never

Very rarely

Sometimes

Usually

2007. I can relax:

Always

Usually

Often

Never

2008. I feel like everything is becoming harder for me:

Almost always

Very often

Sometimes

Never

2009. I have an anxious, tense feeling in my stomach:

Never

Sometimes

Quite often

Very often

2010. I no longer care what I look like:

Indeed, my appearance no longer interests me.

I pay less attention to myself than I should.

Maybe I'm paying slightly less attention to myself.

I pay at least as much attention to myself as normal.

2011. I feel uneasy:

Indeed, very often

Fairly often

Sometimes

Never

2012. I look forward to things with pleasure:

As much as usual

A little less than usual

Much less than usual

Hardly

2013. I suddenly panic:

Indeed, very often

Fairly often

Sometimes

Never

2014. I can enjoy a good book or a radio or TV program:

Often

Regularly

Occasionally

Rarely

Only answer questions 2101-2113 if you're completing this questionnaire for the first time

PCS
Everyone experiences pain in his/her life, such as headache, toothache, joint or muscle pain. People are often in situations that cause pain, such as a dentist's treatment or a surgical procedure.

We're interested in the kind of thoughts and feelings you experience when you're in pain. The following list contains 13 statements that describe different thoughts and feelings that may relate to pain. Try to indicate to what extent these thoughts and feelings apply to you: enter a 0, 1, 2, 3 or 4:

0. Not at all 1. Slightly 2. To a certain extent 3. To a large extent 4. Always

2101. When I'm in pain, I constantly wonder whether the pain will stop.

2102. When I'm in pain, I feel that I cannot go on like this.

2103. When I'm in pain, it's terrible, and I think it will never improve.

2104. When I'm in pain, it's horrible, and I feel overwhelmed by the pain.

2105. When I'm in pain, I feel that I cannot take it any longer.

2106. When I'm in pain, I worry that the pain will worsen.

2107. When I'm in pain, I keep thinking about other painful events.

2108. When I'm in pain, I desperately long for the pain to go away.

2109. When I'm in pain, I cannot get the pain out of my mind.

2110. When I'm in pain, I keep thinking about how much it hurts.

2111. When I'm in pain, I keep thinking about how much I want it to stop.

2112. When I'm in pain, there is nothing I can do to reduce its intensity.

2113. When I'm in pain, I wonder if something serious could happen.

Finally, we'd like to know what your experience was of completing the questionnaire.

How would you rate the questionnaire on the following points:

2206. Can you provide an estimate of how many minutes it took you to complete this questionnaire?

2207. Space for explanation (optional)

Pain Questionnaire