New Patient Questionnaire

To be completed by all new patients. Your medical history, as described in this questionnaire, will form the basis of your assessment with DR Krishna It provides essential background information regarding your pain condition, and makes the consultation process more efficient.

Please ensure you fill in the required fields marked with an asterisk (*)

Name*
First Last
Landline Number*
Mobile Number*
UK Contact Phone Number*
Your Email*
Skype ID (if applicable)
Address*
Street Address City State / Province / Region ZIP / Postal Code
Age*
Date of Birth*
DD slash MM slash YYYY
How did you find out about our clinic?*
GP Details
GP name or practice/surgery/private clinic*
Describe the pain
Please tell us the exact site of the pain (i.e. arm, lower back, neck)
Please describe the 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.)
Is there anything that relieves the pain? (i.e. rest, lying down, sleep)
What investigations have you had for your pain? (i.e. x rays, MRI etc.)
Do you have any medical illnesses? (i.e. asthma, diabetes, high blood pressure etc)
What previous surgeries, if any, have you had? (i.e. appendix, hip replacement etc)
Are you allergic to any drugs, medicines, foods etc? If yes, please provide the name of the drug or allergen and your reaction.
What pain killer medications (tablets/drugs) are you currently taking? Please mention the dose and the frequency of these drugs.
Please list any other medications (apart from pain killers mentioned above) you are currently taking for your health problems (for example tablets for your heart, diabetes and so on)
Are you on any blood thinning drugs like Aspirin, Clopidogrel, Warfarin, Rivaroxaban and so on?
What treatments have you had and what was their outcome?
Nerve Blocks
Outcome
Other Information
Do you have any other symptoms associated with your pain? (i.e. difficulty dressing etc)
How mobile are you? (fully, moderate, wheel chair bound)
Please provide any other information you feel is relevant to your case
Questions
Throughout our lives, most of us have had pain from time to Yes time (such as minor headaches, sprains and toothaches). No Have you had pain other than these every day kinds of pain?
Please tell us where you are feeling pain. E.G 'Lower back' or 'base of skull' etc. Note as many areas as needed.
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)
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)
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)
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)
What treatments or medications are you receiving for your pain?
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)
Indicate below the one number that describes how, during the past 24 hours, pain has interfered with your:
General activity
Mood
Walking ability
Normal work (includes both work outside the home and housework)
Relations with other people
Sleep
Enjoyment of life
Phone
This field is for validation purposes and should be left unchanged.

Please note, all information given on this proforma remains confidential. 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, Pain Spa Limited accepts no responsibility for advice/information given relating to any incomplete, inaccurate or incorrect information you have provided.

GP Details

Describe the pain

What treatments have you had and what was their outcome?

Other Information

Questions

Indicate below the one number that describes how, during the past 24 hours, pain has interfered with your: