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
pijnpo@zha.nl

Personal details

General information

Pain symptoms

Work situation

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

GPE

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?

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)?

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 ...

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.

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)

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.

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.

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.

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

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

How would you rate the questionnaire on the following points:

Conclusion

Thank you for completing this questionnaire. Your answers will be handled confidentially.