Hi .. I was sent home with a bundle of forms to fill in .. I thought it may be useful for others on the forum.

Hope this works .. I typed it out in Word ..

PATIENT QUESTIONNAIRE PRE SCS

Please answer the following questions on a scale of 1 . 10 by circling the appropriate number



(Obviously am not putting the numbers in ... just the question or we’d be here all day)

1. What number best describes your pain on average over the last week?
2. How distressing have you found your pain on average over the last week?
3. How much does your pain interfere with your ability to sleep?
4. IN the past week how much pain relief have you experienced from your pain medications or treatments? Please circle the appropriate percentage?
5. Are you working at present?
6. If you are not working, is this because of your pain?

Medication: You have to give a list of your current medications.


HAD SCALE

Doctors are aware the emotions play an important part in most illnesses. If your doctor knows about these feelings he will be able to help you more.
This questionnaire is designed to help your doctor to know how you feel. Read each item and place a firm tick in the box opposite the reply, which comes closest to how you have been feeling in the last week.
Don’t take too long over your replies: your immediate reaction to each item will probably be more accurate than a long thought-out response.

1. I feel tense or “wound up”
Most of the time
A lot of the time
Time to time – occasionally
Not at all

2. I still enjoy the things I used to enjoy
Definitely not as much
Not quite to much
Only a little
Hardly at all

3. I get a sort of frightened feeling as if something awful is going to happen
Very definitely and quite badly
Yes, but not too badly
A little, but it doesn’t worry me
Not at all

4. I can laugh and see the funny side of things
As much as I always could
Not quite so much now
Definitely not so much now
Not al all

5. Worrying thoughts go through my mind
A great deal of the time
A lot of the time
From time to time but not too often
Only occasionally

6. I feel cheerful
Not at all
Not often
Sometimes
Most of the time

7. I can sit at ease and feel relaxed
Definitely
Usually
Not often
Not at all


8. I feel as if I am slowed down
Nearly all the time
Very often
Sometimes
Not at all

9. I get a sort of frightened feeling like “butterflies” in the stomach
Not at all
Occasionally
Quite often
Very often

10. I have lost interest in my appearance
Definitely
I don’t take so much care as I should
I may not take quite as much care
I take just as much care as ever

11. I feel restless as if I have to be on the move
Very much indeed
Quite a lot
Not very much
Not at all

12. I look forward with enjoyment to things
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all

13. I get sudden feelings of panic
Very often indeed
Quite often
Not very often
Not at all

14. I can enjoy a good book or radio or tv programme
Often
Sometimes
Not often
Very seldom




PCS

Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, toothache, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery.

We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the following scale please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.

0 – Not at all
1 – To a slight degree
2 – To a moderate degree
3 – To a great degree
4 – All the time

When I am in pain:

1. I worry all the time about whether the pain will end
2. I feel I cant go on
3. Its terrible and i think its never going to get any better
4. Its awful and I feel that it overwhelms me
5. I feel I cant stand it anymore
6. I become afraid that the pain will get worse
7. I keep thinking of other painful events
8. I anxiously want the pain to go away
9. I cant seem to keep it out of my mind
10. I keep thinking about how much it hurts
11. I keep thinking about how badly i want the pain to stop
12. Theres nothing I can do to reduce the intensity of the pain
13. I wonder whether something serious may happen


PAIN : S-E QUESTIONNAIRE

Please rate how confident you are that you can do the following things at present, despite the pain. To answer circle one of the number of the scale 0 – 6 under each item. 0 being not at all confident and 6 being completely confident.

1. I can enjoy things despite the pain
2. I can do most of the household chores (e.g. tidying up, washing dishes and so on)
3. I can socialise with my friends or family members as often as i used to, despite the pain.
4. I can cope with my pain in most situations
5. I can do some form of work despite the pain .. (work includes, housework, paid or unpaid work)
6. I can still do many of the things I enjoy doing, such as hobbies or leisure activities despite the pain.
7. I can cope with my pain without medication
8. I can still accomplish most of my goals in life, despite the pain.
9. I can live a normal lifestyle despite the pain.
10. I can gradually become more active, despite the pain.


PASS

Individuals who experience pain develop different ways to respond to that pain. We would like to know what you do and what you think about when in pain. Please use the raging scale below to indicate how often you engage in each of the following thoughts or activities. Circle and number from o (never) to 5 (always) for each item.

1. I think that if my pain gets too severe, it will never decrease.
2. My mind is calm when i am in pain
3. When I feel pain I try to stay as still as possible
4. I become sweaty when in pain
5. When i feel pain i am afraid that something terrible will happen
6. My thoughts are agitated and keyed up as pain approaches
7. I go immediately to bed when i feel severe pain
8. Even though it hurts I know that I am going to be ok.
9. My body gets shaky when i hurt
10. I feel disorientated and confused when i hurt
11. When pain gets severe, I call my doctor or go to the emergency room.
12. I begin trembling when engaged in an activity that increases pain
13. When I feel pain i become afraid of dying
14. I cant think straight when i am in pain
15. I will stop any activity as soon as i sense pain coming on
16. Even if i do an activity that causes pain i know it will decrease later
17. Pain seem to cause my heart to pound or race
18. I think i have a serious medical problems that my doctor has failed to discover
19. As soon as pain comes on I take medication to reduce it
20. I have pressure or tightness in my chest when in pain
21. When I feel pain i think that i might be seriously ill
22. During painful episodes it is difficult for me to think of anything besides the pain
23. I avoid important activities when I hurt
24. When I sense pain i feel dizzy or faint
25. Pain sensations are terrifying
26. When i hurt i think about the pain constantly
27. I take medication if i know i need to do something that usually increases the pain
28. I have trouble catching my breath when i have pain sensations
29. I dread feeling pain
30. I am bothered by unwanted thoughts when i am in pain
31. If a chance comes to do something i enjoy i do it even if it causes pain
32. Pain makes me nauseous
33. When pain comes on strong I think that i might become paralysed of more disabled
34. I find it hard to concentrate when i hurt
35. I see reassurance that i am okay during times of more severe pain
36. I find it difficult to calm my body down after periods of pain
37. I worry when I am in pain
38. My stomach bothers me when i am in pain
39. I try to avoid activities that cause pain
40. I can think pretty clearly even when experiencing severe pain