Please fill out the following Questionnaire for details of you pain. Pain Evaluation Questionnaire I. Pain area (choose all that apply) 1. Headache in the forehead behind the head on either or both sides of the head on top of the head 2. Chest pain right in the heart under the xiphoid process 3. Shoulder pain my arm cannot raise forward my arm cannot lift and comb the hair my arm cannot reach backward to the back 4. Flank pain (between the ribs and the hip) Yes 5. Epigastric pain (slightly under the xiphoid process) Yes 6. Abdominal pain upper abdomen lower abdomen lateral lateral lower abdomen peri-umbilicus 7. Backache Yes 8. Tenderness on the spine? Yes, I have tenderness on the spine, and it is under the following vertebra. Location of the tenderness 9. Waist pain Yes 10. Pain in the limbs Fingers Wrist Palm Back of the hand Bottom of the foot Back of the foot Ankle Heel 11. Whole body pain Yes II. Pain timing & conditions (choose all that apply) 1. How long ago did the pain start? Within a week Between 1-2 weeks More than 2 weeks ago 2. Under what conditions does the pain occur? 3. What happens when you press on the pain spot? It feels better It gets worse 4. What happens when you apply hot or cold compress on the pain area? It feels better under hot compress It feels better under cold compress 5. Under what circumstances would the pain improve? During the improvement, what symptoms would accompany it? III. Nature of pain 1. Distending pain (a combination of swelling and pain) Yes 2. Stabbing pain (feel like being pricked by a needle or cut by a knife) Yes 3. Cold pain (a combined feeling of cold and pain) Yes 4. Burning pain Yes 5. Heavy pain (body feels heavy, and hard to raise hands or feet) Yes 6. Soreness (uncomfortable but not obvious) Yes 7. Extreme pain (as if wringing by a knife inside the body) Yes 8. Empty pain (feels empty in the lower abdomen) Yes 9. Dull pain (mild and happens from time to time) Yes 10. Moving pain Yes 11. Fixed pain Yes 12. Pulling pain (the pain spot feels like pulled by another part of body) Yes Other details Name (First, Last) * Phone # Email * Note If you are human, leave this field blank. Submit