R3-health-questionnaire

(If you have more than one painful are or more than one kind of pain describe their locations separately. Please indicate which one is your worst pain or primary problem.)

Describe the kind of pain (s) you have? That is, which is the quality or character of your pain? If you r pain(s) are different in different places, please tell which words describe the pain in each location.

(The closest date to our best recollection) if your pain is due to an injury, a short illness, or a surgical procedure, give the date that the pain causing event occurred. (If you can’t give an exact date, please give the time period over which the problem began.)

(What injury or other event was associated with the start of your pain?)

How much time went by after this event until the pin started? (ex; hours, days. Months, weeks?)

(List all things, medicines, treatments, postures, activities, or anything else, which seems to worsen your pain.)

(List ALL OTHER medicines you take right now, including herbal or homeopathic remedies, vitamins, and non-prescription drugs).

a. Operation was a complete success
b. Original pain as less after the operation
c. Original pain was the same after the operation
d. Original pain was relieved after the surgery but came back
e. Operation produced different pain (explain)
f. Original pain was worse after the operation

Has anyone in your family (parents, brother(s) or sisters (s), spouse, children had a chronic, painful condition? List who and what they had.

Is there any information not requested on this questionnaire that you think might be important or relevant to your case? If so, please use this space to give us your thoughts?