New Fibro Patient Questionnaire

To be completed by all new patients. Please note; All clinical information that we hold regarding the assessment and treatment of our patients, for best practice purposes, is sent to patients' GPs so that primary care providers can see precisely what you have presented with and how we are treating you. Your medical history as described by you in this questionnaire forms the basis of the assessment with your Consultant and provides essential background information regarding your pain/condition, and as such it is sent to your GP with your clinic assessment.

    It is essential that we are able to keep your GP/registered practice informed in relation to your treatment and medication
    GP name or practice/surgery/private clinic
    Number
    Email
    Address
    Insurance Details
    Insurance Company Name
    Insurance Company Policy Number
    Insurance Pre-authorisation code for the appointment
    Personal Details
    Name (including title)
    Address
    Daytime Contact No's
    Date of Birth (DD/MM/YYY)
    Age
    Your Email
    Describe the pain
    Site of the pain (i.e. arm, lower back, neck)
    Character of the pain (i.e. Sharp, burning, pricking, stabbing, aching, etc.). Please try and explain in your own words.
    When did the pain start?
    Is there anything that precipitated the pain? (i.e. accident, illness etc.)
    How often do you get the pain (i.e. continuous, daily, hourly etc.)
    Does the pain radiate to any other part of the body?
    What things aggravate the pain? (i.e. standing, walking etc.)
    What medication (tablets/drugs) are you currently taking?
    What investigations have you had for your pain? (i.e. x rays, MRI etc.)
    What treatments have you had and what was their outcome? (i.e. Treatment = 2 epidurals, Outcome = effect lasted only a few weeks)
    Treatment Outcome
    Medication:
    Outcome
    Physiotherapy:
    Outcome
    Alternative Medicine:
    Outcome
    Nerve Blocks:
    Outcome
    Surgery:
    Outcome
    Advanced pain management techniques (i.e. spinal cord stimulator):
    Outcome

    Other Information
    Do you have any other symptoms associated with your pain? (i.e. difficulty dressing etc)
    Do you have any medical illnesses? (i.e. asthma, diabetes, high blood pressure etc)
    What previous surgeries have you had? (i.e. appendix, hip replacement etc)
    Please provide any other information you feel is relevant to your case
    Question Answer
    1 Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and
    toothaches). Have you had pain other than these every day kinds of pain?
    YesNo
    2 Please tell us where you are feeling pain. E.G 'Lower back' or 'base of skull' etc. Note as many areas as needed.
    3 Please rate your pain by number that best describes your pain at its worst in the last 24 hours. (0 - no pain / 10 – pain as bad as you can imagine)
    4 Please rate your pain by number that best describes your pain at its least in the last 24 hours. (0 - no pain / 10 – pain as bad as you can imagine)
    5 Please rate your pain by number that best describes your pain on the average. (0 - no pain / 10 – pain as bad as you can imagine)
    6 Please rate your pain by number that tells how much pain you have right now.
    (0 - no pain / 10 – pain as bad as you can imagine)
    7 What treatments or medications are you receiving for your pain?
    8 In the last 24 hours, how much relief have pain treatments or medications provided? Please give a percentage that most shows how much relief you have received. (0% - no relief / 100% - complete relief)
    9 Indicate below the one number that describes how, during the past 24 hours, pain has interfered with your:
    (0- does not interfere / 10 – completely interferes)
    A General activity
    B Mood
    C Walking ability
    D Normal work (includes both work outside the home and housework)
    E Relations with other people
    F Sleep
    G Enjoyment of life
    Fibromyalgia/Chronic Fatigue-specific questions:
    How much has fatigue/pain decreased your functioning?
    What stresses did you have in your life when your illness began?
    Are you married, single, divorced or widowed?
    How many hours were you working per week at the onset of your illness (this is aside from caring for your
    family)?
    Did you have to change jobs or decrease your work hours because of your illness?
    Do you have any family members with fibromyalgia/chronic fatigue syndrome?

    SYMPTOM CHECKLIST

    Answer the following questions by selecting Yes or No.

    ME/CFS CRITERIA:
    Is your fatigue not lifelong, it is not the result of ongoing exertion, is it not substantially alleviated by rest, and has it substantially reduced your participation in occupational, educational, social or personal activities? yesno
    Do you have four or more of the following symptoms? To apply, the symptom must have persisted or recurred during six or more consecutive months of illness and must not predate fatigue.
    A. Self-reported impairment of short-term memory or concentration that is severe enough to have caused a substantial reduction in your participation in occupational, educational, social, or personal activities. yesno
    B. Sore throat. yesno
    C. Tender neck or axillary (armpit) lymph nodes. yesno
    D. Muscle pain. yesno
    E. Multi-joint pain without joint swelling or redness. yesno
    F. Headaches of a new type, pattern, or severity. yesno
    G. Unrefreshing sleep. yesno
    H. Post-exertion fatigue lasting for more than twenty-four hours. yesno
    FIBROMYALGIA CRITERIA
    Have you had chronic widespread pain for more than three months in all four quadrants of your body (above and below your waist and on both sides of your body)? Have you also had axial pain (pain around your spine or chest)? yesno
    When you exercise, do you feel worse afterwards and exhausted the next day? yesno

    Please note, all information given on this proforma remains confidential and is held securely by London Pain Clinic in accordance with the Data Protection Act 1998.The information is used to help simplify your assessment and to enable maximum time to be spent on examination and discussion during your assessment. It is no way a substitute for a full consultation and examination. Thank you for taking the time to complete this questionnaire.

    Please note that the outcome will be based on the information you have provided. Therefore, London Pain Clinic accepts no responsibility for advice/information given relating to any incomplete, inaccurate or incorrect information you have provided.