PAIN QUESTIONNAIRE

A Screening questionnaire to identify neuropathic components in patients with pain.

This Questionnaire does not replace medical diagnostics.
It is used for screening the presence of a neuropathic pain component.

Email
Name
Phone Number
Date of Birth (DD/MM/YYYY)

How would you assess your pain now, at this moment?

How strong was the strongest pain during the past 4 weeks?

How strong was the pain during the past 4 weeks on average?

Choose the number that best describes the course of your pain:


Pain patterns

Does your pain radiate to other regions of your body?

Do you suffer from a burning sensation (e.g., stinging nettles) in the marked areas?

Do you have a tingling or prickling sensation in the area of your pain (like crawling ants or electrical tingling)?

Is light touching (clothing, a blanket) in this area painful?

Do you have sudden pain attacks in the area of your pain, like electric shocks?

Is cold or heat (bath water) in this area occasionally painful?

Do you suffer from a sensation of numbness in the areas that you marked?

Does slight pressure in this area, e.g., with a finger, trigger pain?

Are you taking any prescription medication ? If Yes,  Please List 

Do you have any allergies ? If Yes, Please List 

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