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Pain Questionnaire Form
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Pain scores and description
Title
*
Mr
Mrs
Ms
Miss
Full Name
*
Date
*
Please rate your pain at its WORST in the past 24 hours
*
1
2
3
4
5
6
7
8
9
10
(0 = No pain, 10 = Worst imaginable pain)
Please rate your pain at its LEAST in the past 24 hours
*
1
2
3
4
5
6
7
8
9
10
(0 = No pain, 10 = Worst imaginable pain)
much your at
Please rate your pain level on an AVERAGE
*
1
2
3
4
5
6
7
8
9
10
(0 = No pain, 10 = Worst imaginable pain)
In the past 24 hours, how much RELIEF have pain treatments or medications provided?
*
1
2
3
4
5
6
7
8
9
10
(0 = Not much relief, 10 = A lot of relief)
Number that describes how much your pain has INTERFERED with your life in last 24 hours
*
1
2
3
4
5
6
7
8
9
10
(0 = No interference at all, 10 = I am unable to function/cope)
Describe your pain area
Submit
Home
About Us
Pain Treatment
Pain Management
Non-Invasive Pulsed Radiofrequency – PRF
Interventional Pain Procedure
Opioid Treatment
Contact
Resources
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Dr. Angela Dastouri
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Dr. Adam Mir
