Læknaneminn - 01.04.1994, Side 46

This questionnaire has been designed to tell us more about your pain.
Four major questions we ask are:
1. Where is your pain?
2. What does it feel like?
3. How does it change with time?
4. How strong is it?
It is important that you tell us how pain feels now. Please follow the
instructions at the beginning of each part.
Párt 4 How strono is vour pain?
People agree that the following five words represent pain in increasing
intensity. They are:
1 2 3 4 5
Mild Discomforting Distressing Horrible Excruciating
To answer each question below, write the number of the most appropriate
word in the space beside the question.
1. Which word describes your pain right now?
2. Which word describes it as its worst?
Please mark on the drawings below, the areas where you feel pain. Put F if
external, or I if internal, near the areas which you mark. Put El if both external
and internal.
3. Which word describes it when it is least?
4. Which word describes the worst toothache you ever had?
5. Which word describes the worst headache you ever had?
6. Which word describes the worst stomach-ache you ever had?
Part 2 What does vour pain feel like?
Some of the words below describe your present pain.CircleQNLY those
words that best describe it. Leave out any category that is not suitable. Use
only a single word in each appropriate category-the one that applies best.
1. How long have you been experiencing pain?
-1. Less than 1 week
-2. More than 1 week, but less than 1 month
-3. 1 to 3 months.
-4. 3 to 6 months
-5. Greater than 6 months
2. Are you presently taking any medication for the purpose of relieving pain?
-1. Yes
-2. No
-9. Not sure
3. If you have be$n taking any medication for pain relief, how long have you
been taking it?
-1. Less than 1 week
-2. More than 1 week, but less than 1 month
-3. 1 to 3 months
-4. 3 to 6 months
-5. Greater than 6 months
-9. Not applicable
4. How much relief are you presently getting from the medication for pain?
-1. None
-2. Slight
-3. Moderate
-4. Almost total
-5. Total
1 2 3 4 5
Flickering Jumping Pricking Sharp Pinching
Quivering Flashing Boring Cutting Pressing
Pulsing Throbbing Beating Pounding Shooting Drilling Stabbing Lancinating Lacerating Gnawing Cramping Crushing
6 7 8 9 10
Tugging Hot Tingling Dull Tender
Pulling Burning Itchy Sore Taut
Wrenching Scalding Searing Smarting Stinging Hurting Aching Heavy Rasping Splitting
11 12 13 14 15
Tiring Sickening Fearful Punishing Wretched
Exhausting Suffocating Frightful Terrifying Gruelling Cruel Vicious Blinding
16 17 18 19 20
Annoying Spreading Tight Cool Nagging
Troublesome Radiating Numb Cold Nauseating
Miserable Intense Unbearable Penetrating Piercing Drawing Squeezing Tearing Freezing Agonizing Dreadful Torturing
Part 3 How does vour pain chanoe with time?
1. Which word or words would you use to describe the pattern of your pain?
5. How long do you get pain relief from the present medication?
-1. 1 to 3 hours
-2. 3 to 6 hours
-3. 6 to 9 hours
-4. 9 to 12 hours
-5. Greater than 12 hours
6. Have you experienced any uncomfortable side-effects from the pain
medication?
-1. Yes
-2. No
-3. Not sure
7. Have you tried any of the following procedures for pain alleviation in the
past (other than medication)?
-1. Acupuncture
-2. Transcutaneous stimulator
-3. Biofeedoack/hypnosis/meditation
-4. Nerve blocks
-5. Neurosurgery
-6. Other (specify)
-9. None
8. If so, did you receive any relief from pain?
-1. Yes
-2. No
-9. Not sure
9. Pain is the most troublesome (circle the answer that suits you);
-1. In the morning
-2. In the afternoon
-3. In the evening
-4. During the night
-5. There is no change during the day
Continuous
Steady
Constant
2
Rhythmic
Periodic
Intermittent
3
Brief
Momentary
Transient
2. What kind of thinas relieve your pain?
3. What kind of thinas increase your pain?
10. Does your pain presently interfere with you falling asleep?
-1. Yes
-2. No
-3. Not sure
11. Do you presently need or are you taking extra medication to enable you
to sleep?
-1. Yes
-2. No
-9. Not sure
12. Are you presently awakened by pain once you have fallen asleep?
-1. Yes
-2. No
-9. Not sure
Mynd 3. MC-GILL spwningalistinn (19).
40
LÆKNANEMINN 1 1994 47. árg.