Pain Assessment Tool - Relief and Treatment Options

Please indicate your age:

Under 18 years

18 - 30 years

31 - 45 years

46 - 60 years

Over 61 years

Please indicate your gender:

Male

Female

Approximately, how long have you been experiencing pain?

Less than 3 months

3 to 6 months

More than 6 months

How would you rate the intensity of your pain overall?

Mild

Moderate

Severe

Where in your body do you experience pain? (select all that apply)

Foot/ankle

Hip

Leg

Back

Shoulder

Arm

Hand/Wrist

Other

Have any of the following conditions been diagnosed as the primary cause of your pain?

Disc herniation/disc disease

Complex Regional Pain Syndrome (CRPS) or Reflex Sympathetic Dystrophy (RSD)

Failed Back Syndrome

Pain caused by cancer

Peripheral nerve injury

Not diagnosed

Which of the following pain management treatments have you tried? (select all that apply)

Pharmacy medications (e.g. aspirin, ibuprofen, codeine)

Prescription medication

Physiotherapy and/or chiropractic care

Alternative therapies (e.g. massage, acupuncture)

Cognitive Behavioural Therapy (CBT)

Injection therapy (nerve blocks)

Corrective surgery

Implantable neurostimulation

Implantable drug delivery

Neuroablation (destruction of nerves)

I have not received any of these treatments

What type of healthcare professional provides treatment for your pain? (Select the practitioner you see most)

GP/ Family Doctor

Orthopaedic surgeon

Neurosurgeon

Chiropractor

Pain Management Specialist

Rheumatologist

Physiotherapist

Oncologist

Neurologist

Cardiologist

Complementary medicine practitioner

Are you satisfied with the level of pain relief your current treatment provides?

Yes

No

Q10 Can you tolerate the side effects of your current treatment?

Yes

No

Q11 Can you manage your symptoms and perform most normal daily activities?

Yes

No

Important: Medtronic Australasia respects the confidentiality of your personal information. Your responses will not be shared with any outside companies. Medtronic will use the information in accordance with the Medtronic Privacy Statement.