How to fill this form?
Item number 1-6: Your personal details. This is required for contacting you in different situations like: change of appointment time and/or date, cancelling appointment in emergency situation, availability of
experts from other city/country for free consultation etc.
Item number 7: You should mention duration of sufferings. You may write the whole duration of pain and specify duration (or date if you remember it) when the pain has started to worsen.
Item number 8-10: We should have some idea about the quantity or amount of pain. This is a simple numerical tool to assess pain. First you should imagine the maximum pain you can tolerate. This is totally
imaginary, not your present & actual pain. One will die out of pain if pain is increased slightly more than this this maximum pain (out of shock). This maximum imaginary pain = 10. So there can not have pain of 10.1 or 11 according to this scale. If there is no pain, then the score will be 0. So your actual or real pain must lie somewhere between 0 to 10. In item number 8, put your present pain. In item number 9, the maximum pain you felt in last one month and in item number 10, you should make an average of all pain you felt over last one month.
Item number 11. Here we want to know the pattern of pain over 24 hours. Cross box 1. if your pain remains same throughout the day without any fluctuation (increase or decrease of pain). Cross box 2. if your
pain comes suddenly and there is no pain in between these attacks of pain. Cross box 3. if there are sudden severe attacks of pain with a constant baseline residual pain. In other words, there is always
some amount of pain with increase of pain at times. Cross box 4. if baseline pain is minimal as well as pain attacks. This is same as box 3. only in mild form.
Item number 12: Put yes, if your pain starts from one part and spreads or radiates to other parts of body. Put no, if pain is not moving or spreading and remaining constantly at same position.
Item number 13: With a pen or pencil mark area or areas of pain on the pictures.
Item number 14: This box with seven questions are to identify quality or nature of pain. Carefully read all questions, understand its meaning and put mark in appropriate box. Mark only once for each question
which can best explains your sufferings.
Item number 15: We want to know if you have any other complains or symptoms or sufferings other than pain.
Item number 16: Most pain fluctuates throughout the day and night. Tell us the time when you feel maximum pain in a day. If your pain is constant (very rare) write "constant pain without fluctuations".
Item number 17: Read the different patterns of sleep described below. Mark which explains your sleep best.
Item number 18: Intensity of pain usually changes with change of posture of body. Mark the posture/s which increases your pain; it may be more than one.
Item number 19: Write the name of medicines you have take for pain. Even you may bring the strips of medicine for our check up.
Item number 20: Mark accordingly.
Item number 21: Name of the disease/s you are suffering or you have suffered in past. Mention if you feel that it might have some relevance with your present pain.
Item number 22: If you have suffered from any injury/ accident please mention it. Mention date and injured body part.
Item number 23: Mention all operations with dates. If you have been operated for pain, mention any change of quality, quantity and distribution of pain before and after surgery.
Item number 24: Here we want to see the impact of pain in your mind. Read the box carefully and cross only once for each questions.
Relax, take time and think before filling this form. Filling this form will help us to diagnose your condition in a better way. If you have any doubts/questions in filling this form ask us on 033-65361629 (11AM -
5PM). If it is still not clear you may keep that part blank. But you must bring at least partially filled form before you visit us for consultation.