my pain questionnaire€¦ · waves that come and go. iron on my skin. fire . my pain questionnaire...
TRANSCRIPT
. . . waves that come and go.
. . . a hot iron
on my
skin.
...a fire under my skin.
My Pain questionnaireHow would you describe your Pain?
use this questionnaire to help describeaccurately how your pain feels. you can tick as manyboxes as you wish. this questionnaire can assist your
doctor in making the right diagnosis for you.
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... metal filings under my skin
... (hot) pins and needles
... a hit from a hammer
... a (open fresh) wound
... a cut from a knife
... chilli pepper in my mouth
... something that squeezes me
... a rubbing sensation
... a volcano erupting
... waves that come and go
... a knife being stabbed into my back
... a fire under my skin
... a burning sensation that runs through my back into my legs
... sharp spasms
... an electric shock
... a dull ache that is radiating across the top of my hips
... a sharp shooting down my legs
... a hot iron on my skin
... bad sunburn that won’t go away
... pain after shaving and putting aftershave on
... nagging toothache
... being scolded with hot water
... ants crawling under my skin
... icy / cold sensation
... other (please specify below)
my Pain feels like... Multiple choice selection
2/6
you can also find this questionnaire online and have the chance to print out or send yourself per email
the summary of your individual entries at
www.mypainfeelslike.com
... throbbing
... intense
... nagging
... cutting
... pulsating
... scalding
... unbearable
... shooting
... inconsistent
... itchy
... nipping
... tingling
... temporary
... continuous
my Pain is...Multiple choice selection
...debilitating
... annoying
... a grating pain
... a shearing pain
... so bad it brings tears to my eyes
... located at the area where I had shingles/herpes-zoster before
... located at the area where I had surgery before
... the pain is located in a specific area, and not related to any injury or disease that I can remember
... other (please specify below)
less than 3 months more than 3 months
i suffer from my pain since…
more than 1 year
* Pal M. et al. Curr Pharm Des. 2009; 15(9): 1008-26** Mick G et.al. Pain Management 2012;2(1):71-77.
neuropathic pain affects around 26 million patients worldwide* and approximately 60% of
these suffer from localized symptoms**
www.mypainfeelslike.com
3/6
... frustrated
... tired due to lack of sleep
... irritable
... unable to have a social life
... unable to have intimate relationship
... unable to have my skin touched
... exhausted
... depressed
... agitated
... sad
... unable to walk far
... feel sick
my Pain affects me because it makes me...Multiple choice selection
... lonely
... stressed
... feel useless
... angry
... feel tormented
... misunderstood
... feel undignified because I can’t wear specific clothes
... other (please specify below)
on a scale from 0 – 10, my pain intensity is at its worst (0 = no pain, 10 = pain as bad as you can imagine)
0 1 2 3 4 5 6 7 8 9 10
what would be an acceptable pain level for you?
0 1 2 3 4 5 6 7 8 9 10
www.mypainfeelslike.com
4/6
deep inside my body superficial on the skin
wHere do i feel my Pain?Highlight the areas of the body where you feel pain the most and tick one of the boxes:
if you ticked the box “superficial on the skin” your doctor might be more familiar with the terms: burning, stabbing, shooting, allodynia or hyperalgesia.
www.mypainfeelslike.com
any other information you want to share with your doctor?
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For more information please visit
Developed in collaboration with Montescano Pain School. www.montescanoschool.eu
For more information visit www.grunenthal.com
www.mypainfeelslike.com
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The next step is to book an appointment with your doctor and to take the completed
“my pain questionnaire” along with you, to enable your doctor to better understand your pain.