Please fill out the following Questionnaire for details of you pain.

Pain Evaluation Questionnaire
I. Pain area (choose all that apply)
1. Headache
2. Chest pain
3. Shoulder pain
4. Flank pain (between the ribs and the hip)
5. Epigastric pain (slightly under the xiphoid process)
6. Abdominal pain
7. Backache
8. Tenderness on the spine?
9. Waist pain
10. Pain in the limbs
11. Whole body pain
II. Pain timing & conditions (choose all that apply)
1. How long ago did the pain start?
3. What happens when you press on the pain spot?
4. What happens when you apply hot or cold compress on the pain area?
III. Nature of pain
1. Distending pain (a combination of swelling and pain)
2. Stabbing pain (feel like being pricked by a needle or cut by a knife)
3. Cold pain (a combined feeling of cold and pain)
4. Burning pain
5. Heavy pain (body feels heavy, and hard to raise hands or feet)
6. Soreness (uncomfortable but not obvious)
7. Extreme pain (as if wringing by a knife inside the body)
8. Empty pain (feels empty in the lower abdomen)
9. Dull pain (mild and happens from time to time)
10. Moving pain
11. Fixed pain
12. Pulling pain (the pain spot feels like pulled by another part of body)