How to Complete the Questionnaire

Whether you have received our client questionnaire through the mail or have decided to complete it over our website, the following tips will help assist you in ensuring you provide all the necessary information the doctor requires to prepare a robust and comprehensive report for you.

We have completed some sections below in italics below to help guide you as to the level of detail required.

Please note: If you choose to complete the client questionnaire on paper and send it back to us, we advise you to photocopy the document and return it recorded delivery to ensure it is not lost. It must have the correct postage or we will not receive it (large letter).

Please Return the form to 1 Frances Cottages, Denby Road, Cobham, Surrey KT11 1JT 

  • Use black ink if possible
  • Ensure you write legibly so the doctor can read it.
  • If you need help completing the form please call us on us on 020 7118 0650
  • Take your time to complete the questionnaire as fully as possible as this will form an important part of the report the doctor will write. This is your opportunity to explain to the court/reader how the pain has impacted your life.

 

Personal Details:

Name (including title) and address:

 

Daytime Telephone Numbers:

 

Email:

 

Age:

 

Gender:

 

History Section:

Date of the accident / incident

The date the accident / surgery / incident happened

 

Brief summary of accident / incident

Keep it Brief – For example, I was the passenger in a car involved in an accident when another car

hit the side of the car I was travelling in causing me serious injuries. The police attended the scene

and I was immobilised on a back-board by the paramedics and taken to hospital by ambulance.

 

Site of the pain (e.g. arm / lower back / neck)

Most of the pain is in my left calf but sometimes the pain moves up my left calf into my lower back

 

Character of the pain (e.g. sharp, burning, pricking, stabbing, aching etc)

I have a constant ache, deep in the muscle of my calf which, often changes to a sharp stabbing pain.

 

When did the pain start?

Enter the date the pain started, or a rough estimate of how long you have had the pain, or how long after the index incident the pain started.

 

How often do you get the pain? (e.g. continuous / daily / hourly etc.)

I feel an aching pain in my calf continuously, but it changes to a sharp stabbing pain at night when I am trying to sleep.  This may last for several hours.

 

Does the pain radiate to any other part of the body?

The pain can travel up my left leg to my lower back and radiate into my buttocks.

 

What things aggravate the pain? (e.g. standing / walking etc.)

Walking for longer than 10 minutes aggravates the pain, turning it from an ache to a sharp stabbing pain. Standing in one position for longer than 2-3 minutes causes the pain to change from an ache to a sharp stabbing pain which causes me to sit down until it passes.

 

What things relieve the pain?

The pain is relieved with XXXX medication. Warm baths and a hot water bottle also help to ease the pain.

 

What medication (tablets / drugs) are you currently taking for your pain?

For example – 30mg of (name of medication) morning and evening and 20mg of (name of medication) in the morning.

 

What other symptoms are linked to the pain? (stiffness / disability / depression / anxiety etc.)

For example I have suffered with depression for the past 9 months as a result of my pain. Depression was diagnosed by my GP in April 2015. I suffer from cramp and pain in my arms and hands as a result of walking with crutches.

 

Do you have any medical illnesses? (asthma / diabetes / high blood / pressure etc.)

For example – I suffer from high blood pressure. This was diagnosed in 2012 and I am receiving treatment from my GP and the hospital. I take (name of medication and dose) to control my blood pressure.

 

What previous surgeries have you had? (e.g. appendix / hip replacement etc.)

Please list any surgeries you have had in the past with the date you had the surgery or at least the year.

 

 

Treatments for pain:

What treatments have you had and their outcome? (e.g. had 2 epidurals but effect lasted only a few weeks).

 

Treatments include:

 

Treatment

Outcome

Medication:

Please list all of the medication you have been prescribed and taken previously to help with your PAIN only. Please include the date and the dose if you can .

 

 

Please advise if the medications were helpful

– for example:

Naproxen was helpful for the short period it was prescribed. It relieved the pain by approximately 80%

 

Physiotherapy:

Please list any physiotherapy you have received, the date and length of time you received physiotherapy and on which part of your body – for example

Mar – Aug 2015 physio on my left arm following surgery

 

Explain how helpful the physiotherapy was in relieving your pain or helping you to become mobile and how long the effect of the physiotherapy lasted.

 

 

 

 

Psychological / Psychiatric Treatments:

Please detail any psychiatric or psychological support/counselling you had, the date you attended and what type of treatment it involved.

for example:

Weekly 121 counselling with a pain psychologist for 12 weeks involving CBT.

 

 

Explain how effective was the counselling/CBT etc?
Alternative Medicine e.g. acupuncture, homeopathy etc.

Please detail any other treatment you have received and the date/length of the treatment.

 

 

How effective was the treatment in treating your pain and how long did you feel the benefit of the treatment for?

 

Pain Management Procedures e.g. Nerve blocks, epidurals, facet joint injections, botox etc.

Please detail any pain management Procedures you have received including dates.

 

Please describe how effective these were in relieving your pain.

 

Surgery:

Please set out any surgical treatment you have undergone to treat your pain including dates.

 

Please describe how effective this was in relieving your pain.

 

 

 

 

Advanced pain management techniques (e.g. spinal cord stimulator)

 

Please detail any treatment you have received, including dates.

 

 

 

Please describe how effective this was/is in relieving your pain and whether any devices such as a spinal cord stimulator are still in situ.

 

 

 


Employment and Activities of Daily Living:

 

VERY IMPORTANT PLEASE NOTE: Complete this section in some detail as it provides your opportunity to tell the court how the pain you have or had impacts your life in your own words. This section is not designed for you to give a medical history, but to help us and the court understand if and how your life has changed as a result of the accident/incident and the pain you are now suffering or have suffered. PLEASE COMPLETE EVERY QUESTION.

 

 

Employment / Working Life:

Are you currently employed?   YES / NO

If so, in what role and for how many hours a week?

For example, ‘I am a shop fitter and I work 40 hours per week Monday to Friday.  I work overtime two weekends a month on a Saturday for 8 hours per day.  My work involves fitting cladding and shelving. I have to lift and carry heavy shelving and climb ladders and bend down frequently.’

 

Were you employed at the time of the accident/incident in question?   YES / NO

If so, in what role and for how many hours a week?

State whether you were employed at the time of the incident. If the role you were doing was different to the current role above, please describe this in a similar way as the example given for question 1.

 

Have you needed to take time off since the accident/incident in question?  YES / NO

If so, please specify the duration and number of times you have been off work:

For example, I have been employed in the role described above for 10 years and the incident happened 3 years ago. I was unable to work for 3 months after the incident as the job required more physical activity than I was able to do.

 

Has your employer been sympathetic to your injuries?   YES / NO

Please specify:

For example, No. My employer was initially understanding about the pain I was experiencing, however my job was at risk after I was unable to work for 3 months – as a result I came back to work earlier than recommended.

 

Have you needed to change your working hours since the accident/incident in question? YES / NO

If so, in what way? 

For example, Yes. After coming back from my 3 month break, I had to reduce my hours from 40 hours a week to 20.

 

Have you adjusted your working practices or arrangements since the accident /incident in question? (e.g. sedentary or light duties only/no lifting/no shift work etc)  YES / NO  

If so, in what way?

For example, I am no longer able to drive a fork lift truck and have been placed on light duties indefinitely.

 

Do you believe your career has been affected by the accident/incident?  YES / NO 

If so, in what way?

For example, Yes, I was employed as a senior manager but had to move to a job-share role to accommodate reduced working hours due to my condition and the only roles available were non-management roles.  I am severely restricted in both my choice of role, company should I wish to change jobs and lack of available part-time senior management roles.

 

Has your relationship with work colleagues changed since the accident/incident in question?  YES / NO

If so, in what way?

For example, Yes, I used to socialise frequently with my work colleagues outside of work, however I am unable to join them on weekend hikes or after work drinks and dinner as I get so tired and my pain prevents me from joining in.  As a result I feel isolated from my colleagues and the time I have had to take off of work for hospital appointments and when I relapse has led to some resentment towards me in the office..

 

Any other information related to work/employment you would like us to know?

Tell us anything you think is relevant for the expert to know about the impact of your condition on your work in this section, if it has not been covered in the sections above.

 

Home and Everyday Life:

Has your home and everyday life been affected since the accident/incident in question? YES / NO   

If so, in what way?

For Example, Yes, I am unable to care for myself and need my husband, mother and children to meet my personal care needs.  I am unable to socialise or take care of my young children because of the constant pain I suffer.  We no longer go out together as a family because of the level of pain I am in.

 

Has your ability to carry out day to day tasks been affected since the accident/incident in question? (e.g. housework/dressing/personal care/cleaning etc) YES / NO

If so, in what way?

For Example, Yes, I can no longer do any housework, I have had to employ a cleaner for 6 hours a week to clean the house and do the laundry.  We have to have a gardener and a window cleaner.  My husband, mother and elder daughter assist me with my personal care, dressing, washing etc.

 

Have you had to modify your home in any way since the accident/incident in question? YES / NO

If so, in what way?

For Example, We have had to have a ramp fitted to the front door to accommodate my wheelchair when I need to use it, there are grab rails around the house, mobility aids including a wet room and elevated toilet in the bathroom.  We have had to purchase an air mattress for our bed to assist with my sleeping.

 

Have you needed additional support at home since the accident/incident in question? YES / NO.  

If so, in what way?

Please add any other support you have needed or still need not covered in your answers above.

 

Have your hobbies and interests changed since the accident/incident in question? YES / NO

If so, in what way?

For Example, I am not able to go out to the cinema or hike or go to gym classes as previously.  I am unable to ride my horse any longer.

 

Any other home / everyday information you would like to share with us?

Please add any other information not included n the section above which you believe would be helpful to expert to know.

 

Personal Relationships:

Before the accident/incident, were you married or in a relationship? YES / NO   

 

Has this changed since the accident / incident in question? YES / NO  

If so, in what way

 My fiancé and I were due to be married, but this has now been put on hold because of my disabilities.

Has your physical / sexual relationship changed since the accident / incident in question? YES / NO

If so, in what way?

For example, my fiancé and I no longer engage in a sexual relationship because of the pain I am in.  This has had a devastating effect on our relationship, which has changed into more of a care role.

 

Has your relationship with other family members changed since the accident / incident in question?  YES / NO   

If so, in what way?

 For example, Yes. Since the accident I find it difficult to leave the house due to the pain, and am very depressed.  I find it difficult to socialise with my family – I am unable to see them unless they come to the house.

 

 Has your relationship with friends changed since the accident / incident in question? YES / NO   

If so, in what way?

 For example, Yes. Depression as a result of the incident makes it hard to stay in touch with friends , I no longer drink alcohol because of my medication and can no longer take part in the 5 a side football team I was in at the weekend.

  

Has your social activity changed since the accident / incident in question? YES / NO   

If so, in what way?

 For example, Yes. no longer see my friends and have become very isolated as a result.  It is difficult for me to go on holiday because of my disability which causes tension between my fiancé and I.

 

 

Any other information regarding relationships you would like to share with us?

 Please use this section to provide any further information that is not in the sections above and may be useful to the doctor. 

 

 Any Other Relevant Information:

 

Please provide any other information you feel is relevant to your case:

 

 

 

BRIEF PAIN INVENTORY – Please complete this form fully

 

QUESTION ANSWER
1

Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and toothaches).  Have you had pain other than these every-day kinds of pain?

 

 

YES / NO

2

On the diagram, shade in the areas where you feel pain.  Put an X on the area that hurts the most.

 

SEE FOLLOWING PAGE FOR DIAGRAM
3

In the last 24 hours, rate your pain at its worst, between 0 and 10. (0 – no pain / 10 – pain as bad as you can imagine)

 

Give a rating between 0 and 10.
4

In the last 24 hours, rate your pain at its best, between 0 and 10. (0 – no pain / 10 – pain as bad as you can imagine)

 

Give a rating between 0 and 10.
5

On the average, rate your pain between 0 and 10.

(0 = no pain / 10 – pain as bad as you can imagine)

 

Give a rating between 0 and 10.
6

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)

 

Give a rating between 0 and 10.
7 What treatments / medications are you receiving for your pain? List any treatments / medications that you are taking to lessen the pain from the incident relevant to your case.

 

8

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)

 

Give a rating between 0% and 10%.
9 Indicate below the one number that describes how, during the past 24 hours, pain has interfered with your activities:

(0 = does not interfere / 10 = completely interferes)

 

 
 9a

General activity

 

Give a rating between 0 and 10.
9b

Mood

 

Give a rating between 0 and 10.
 9c

Walking ability

 

Give a rating between  and 10.
 9d

Normal work (includes work outside the home and housework)

 

Give a rating between 0 and 10.
 9e

Relations with other people

 

Give a rating between 0 and 10.
 9f

Sleep

 

Give a rating between 0 and 10.
 9g

Enjoyment of life

 

Give a rating between 0 and 10.

 

 

S-LANSS Pain Score

Leeds Assessment of Neuropathic Symptoms and Signs (self-completed):

The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale[1] has seven items consisting of five symptom items and two examination items. Usually, the examination items are done by a doctor but the modified version (the S-LANSS or self-report LANSS) allows people to do this themselves. The purpose of these scales is to assess whether the pain that is experienced is predominantly due to nerve damage or not. Both the LANSS and S-LANSS are scored out of 24; a score of 12 or more is strongly suggestive of neuropathic pain. Please note, however, that although the S-LANSS is a useful guide to the type of pain, it should only be viewed as an indicator, and not as a diagnosis.

 

NAME:                                                                        DATE: 

 

This questionnaire can tell us about the type of pain that you may be experiencing. This can help in deciding how best to treat it.

 

Please draw on the diagram below where you feel your pain. If you have pain in more than one area, only shade in the one main area where your worst pain is.

 

On the scale below, please indicate how bad your pain (that you have shown on the above diagram) has been in the last week (where ‘0’ means no pain and ‘10’ means pains as severe as it could be).

 

NONE     0    1    2    3    4    5    6    7    8    9     10    SEVERE PAIN

 

 

Below are 7 questions about your pain (the one in the diagram above).

 

Think about how your pain, as you have shown in the diagram, has felt over the last week. Put a tick against the descriptions that best match your pain.  These descriptions may, or may not, match your pain no matter how severe it feels.

Only tick responses that describe your pain.

 

1.  In the area where you have pain, do you also have ‘pins and needles’, tingling or prickling sensations?

 

a) NO – I don’t get these sensations (0)
b) YES – I get these sensations often (5)
 

2.  Does the painful area change colour (perhaps looks mottled or more red) when the pain is particularly bad?

 

a) NO – The pain does not affect the colour of my skin (0)
b) YES – I have noticed that the pain does make my skin look different from normal (5)
 

3.  Does your pain make the affected skin abnormally sensitive to touch? Getting unpleasant sensations or pain when lightly stroking the skin might describe this.

 

a) NO – The pain does not make my skin in that area abnormally sensitive to touch (0)
b) YES – My skin in that area is particularly sensitive to touch (3)
 

4.  Does your pain come on suddenly and in bursts for no apparent reason when you are completely still? Words like ‘electric shocks’, jumping and bursting might describe this.

 

a) NO – My pain doesn’t really feel like this (0)
b) YES – I get these sensations often (2)

 

5.  In the area where you have pain, does your skin feel unusually hot like a burning pain?

 

a)  NO – I don’t have burning pain. (0)

 

b)  YES – I get burning pain often. (1)

 

 

6.  Gently rub the painful area with your index finger and then rub a non-painful area (for example, an area of skin further away or on the opposite side from the painful area). How does this rubbing feel in the painful area?

 

a)  The painful area feels no different from the non-painful area. (0)
b)  I feel discomfort, like pins and needles, tingling or burning in the painful area that is different from the non-painful area. (5)
 

7.  Gently press on the painful area with your finger tip then gently press in the same way onto a non-painful area (the same non-painful area that you chose in the last question). How does this feel in the painful area?

 

a)  The painful area does not feel different from the non-painful area (0)
b)  I feel numbness or tenderness in the painful area that is different from the non-painful area. (3)

 

 

Scoring: a score of 12 or more suggests pain of a predominantly neuropathic origin

 

 

 

 

[1] Source: Bennett, M et al The Journal of Pain, Vol 6, No 3 March , 2005 pp 149-158 The S-LANNS Score for Identifying Pain of Predominantly Neuropathic Origin: Validation for Use in Clinical and Postal Research The Journal 3.