New 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. Please ensure you fill in the required fields marked with an asterisk (*)
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 Landline Number*
Daytime Mobile Number
If you are normally a resident overseas, could you please provide us with a UK contact phone number.
UK contact phone number:
Date of Birth (DD/MM/YYY) *
Age
Your Email *
Please advise how you found out about our clinic?
Do you have any medical illnesses? (i.e. asthma, diabetes, high blood pressure etc)
Are you allergic to any drugs, medicines, foods etc? If yes, please provide the name of the drug or allergen and your reaction.
Describe the pain
What medication (tablets/drugs) are you currently taking?
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 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)
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

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.