Tel: 03 9125 3969
painadmin@drgloriaseah.com.au
Referral Questionnaire
First Name
Last Name
Date of Birth
Today's Date
Country of Birth
Do you require an interpreter?
Yes
No
If YES, please specify the language
Are you hearing or sight impaired?
Do you require help with written or spoken communication?
Yes
No
Height
Weight
Are you of Aboriginal or Torres Strait Islander Origin?
No
Yes, Aboriginal
Yes, Torres Strait Islander Origin
Have you ever served in the Australian Defence Force?
Yes
No
Are you a client of the Department of Veteran Affairs or have you ever received a benefit or support from Department of Veteran Affairs?
Yes
No
Is there a compensation case relating to this episode?
Workers Compensation
TAC
Public Liability
Other
How did your main pain begin?
Injury at home
Motor Vehicle Crash
After surgery
At work or school
Cancer
No obvious cause
Injury in another setting
Medical condition other than cancer
Other
If Other, please specify
How long has your main pain been present? (Tick one box only)
Less than 3 months
3 to 12 months
12 months to 2 years
2 to 5 years
More than 5 years
Which statement best describes your pain?
Always present (always the same intensity)
Always present (level of pain varies)
Often present (pain free periods last less than 6 hours)
Occasionally present (pain occurs once or several times a day, lasting up to an hour)
Rarely present (pain occurs every few days or weeks)
Do you have any of the following conditions:
A mental health condition, in particular: PTSD Anxiety Depression Other (please specify)
Arthritis (including Rheumatoid/Osteoarthritis)
Muscle, bone and joint problems other than arthritis (including Osteoporosis, Fibromyalgia)
Heart and circulation problems (including Heart Disease, Pacemaker, Blood Disease)
In particular specify if you have: High Blood Pressure High Cholesterol
Diabetes
Digestive problems (including IBS, GORD, Stomach Ulcers, Reflux, Bowel Disease)
Respiratory problems (including Asthma, Lung Disease, COPD, Sleep Apnoea)
Neurological problems (including Stroke, Epilepsy, Multiple Sclerosis, Parkinson’s Disease)
Cancer
Liver, kidney and pancreas problems (including Pancreatitis, Kidney Disease)
Thyroid problems (including Hyperactive or Hypoactive Thyroid, Graves’ Disease)
Any other medical conditions (please specify) .......................................................................................
Please specify answers to the above where requested
How many times in the past 3 months have you seen a GP in regards to your pain?
How many times in the last 3 months have you seen another specialist in regard to your pain?
How many times in the past 3 months have you seen other health professionals other than doctors (physio etc) in regard to your pain?
How many times in the past 3 months have you visited a hospital Emergency Department in regard to your pain?
How many times in the past 3 months have been admitted to hospital as an inpatient because of your pain?
How many diagnostic tests (X rays, scans, blood tests ) have you had in the past 3 months in regard to your pain?
Your Work
Are you currently employed (working for pay)?
Yes, working full time
Yes, working part time
No, unable to work due to a condition other than pain
No, unable to work due to pain
Not working by choice (retired, student, home maker)
Seeking employment (I consider myself able to but cannot find work)
In the past 7 days, how many hours did you miss from work because of problems associated with your pain?
In the past 7 days, how many hours did you actually work?
During the past seven days, how much did your pain affect your productivity while you were working? (Consider only how much pain affected you WHILE you were working)
0
1
2
3
4
5
6
7
8
9
10
Think about days you were limited in the amount or kind of work you could do, days you accomplished less than you would like, or days you could not do your work as carefully as usual. If pain affected your work only a little, choose a low number. Choose a high number if pain affected your work a great deal.
0
1
2
3
4
5
6
7
8
9
10
Please list all medication (NAME, DOSES, TIMES A DAY) you currently take including over the counter medications
Location of pain
*
Clear drawing
Please rate your pain by choosing the ONE number that best describes the following
Your pain at its WORST in the last week
0
1
2
3
4
5
6
7
8
9
10
Your pain at its LEAST in the last week
0
1
2
3
4
5
6
7
8
9
10
Your pain on AVERAGE in the last week
0
1
2
3
4
5
6
7
8
9
10
How much pain do you have RIGHT NOW?
0
1
2
3
4
5
6
7
8
9
10
During the past week, how much has pain interfered with the following (0 - does not interfere, 10 - completely interferes) choose ONE number only
Your general activity?
0
1
2
3
4
5
6
7
8
9
10
Your mood?
0
1
2
3
4
5
6
7
8
9
10
Your walking ability?
0
1
2
3
4
5
6
7
8
9
10
Your normal work (both outside the home and housework)?
0
1
2
3
4
5
6
7
8
9
10
Your relations with other people?
0
1
2
3
4
5
6
7
8
9
10
Your sleep?
0
1
2
3
4
5
6
7
8
9
10
Your enjoyment of life?
0
1
2
3
4
5
6
7
8
9
10
DASS-21 (pick one option only)
I found it hard to wind down
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I was aware of dryness in my mouth
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I couldn't seem to experience any positive feeling at all
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I experienced difficulty breathing (e.g. excessive rapid breathing, breathlessness in absence of physical exertion)
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I found it difficult to work up the initiative to do things
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I tend to overreact to situations
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I experienced trembling (e.g. in the hands)
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I felt that I was using a lot of nervous energy
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I was worried about situations where I might panic & make a fool of myself
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I felt that I had nothing to look forward to
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
i found myself getting agitated
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I found it difficult to relax
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I felt downhearted and blue
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I was intolerant of anything that kept me from getting on with what I was doing with
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I felt I was close to panic
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I was unable to become enthusiastic about anything
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I felt I wasn't worth much as a person
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I felt I was rather touchy
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I was aware of the action of my heart in the absence of physical exertion (e.g. palpitations, skipping a beat)
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I felt scared without any good reason
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
I felt that life was meaningless
0 Not at all
1 Some of the time
2 A good part of the time
3 Most of the time
PSEQ
I can enjoy things, despite the pain
0 not at all confident
1
2
3
4
5
6 completely confident
I can do most of the household chores despite the pain
0 not at all confident
1
2
3
4
5
6 completely confident
I can socialise with my friends & family as often as I used to despite the pain
0 not at all confident
1
2
3
4
5
6 completely confident
I can cope with my pain in most situations
0 not at all confident
1
2
3
4
5
6 completely confident
I can do some form of work despite the pain (work includes paid, unpaid work and housework)
0 not at all confident
1
2
3
4
5
6 completely confident
I can still do many things I enjoy doing such as hobbies or leisure activity despite the pain
0 not at all confident
1
2
3
4
5
6 completely confident
I can cope with my pain without medication
0 not at all confident
1
2
3
4
5
6 completely confident
I can still accomplish most of my goals in life despite the pain
0 not at all confident
1
2
3
4
5
6 completely confident
I can still live a normal lifestyle despite the pain
0 not at all confident
1
2
3
4
5
6 completely confident
I can gradually become more active despite the pain
0 not at all confident
1
2
3
4
5
6 completely confident
PCS
I worry all the time whether the pain will end
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
I feel I can't go on
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
It's terrible and I think it's never going to get any better
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
It's awful and I feel it overwhelms me
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
I feel I can't stand it anymore
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
I become afraid that the pain will get worse
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
I keep thinking of other painful events
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
I anxiously want the pain to go away
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
I can't seem to keep it out of my mind
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
I keep thinking about how much it hurts
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
I keep thinking about how badly I want the pain to stop
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
There's nothing I can do to reduce the intensity of the pain
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
I wonder whether something serious may happen
0 Not at all
1 To a slight degree
2 To a moderate degree
3 To a great degree
4 All the time
Please wait, files are uploading..
Submit
