New Fibro Patient Questionnaire

GP name or practice/surgery/private clinic

Number

Email

Address

Insurance Company Name

Insurance Company Policy Number

Insurance Pre-authorisation code for the appointment

Name (including title)

Address

Daytime Contact No's

Date of Birth (DD/MM/YYY)

Age

Your Email

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.)

Treatment

Outcome

Medication:

Outcome

Physiotherapy:

Outcome

Alternative Medicine:

Outcome

Nerve Blocks:

Outcome

Surgery:

Outcome

Advanced pain management techniques (i.e. spinal cord stimulator):

Outcome

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

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)

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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)

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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)

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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)

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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)

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A

General activity

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B

Mood

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C

Walking ability

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D

Normal work (includes both work outside the home and housework)

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E

Relations with other people

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F

Sleep

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G

Enjoyment of life

—Please choose an option—12345678910

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?

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

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