General Practice Name: <Practice>

REFERRAL QUESTIONNAIRE	
Section 1 – Your details	
Title	
<PtTitle>	

	

	Family name (surname)
<PtSurname>	Given name(s)
<PtFirstName>  <PtMidName>	
Gender	
    <PtSex>	

	

	Date of birth (dd/mm/yyyy)
<PtDoB>	Today’s date (dd/mm/yyyy)
<TodaysDate>	
Address 
<PtAddress>

Phone  Home: <PtPhoneH>               Work: <PtPhoneWk>          Mobile: <PtPhoneMob>

Email address 
<PtEmail>	
Country of Birth	<Country of Birth>			
Do you require an interpreter?	<Does patient require an interpreter?>				
If you answered yes, please specify the language <If patient says YES, please specify the language?>	
Are you hearing or sight impaired?	<Is patient hearing or sight impaired?>				
Do you require help with written or spoken communication?	<Does Pt require help with written or spoken Comms>		
Height (in cm)  <Patient Height in cm>	Weight (in kg)  <Patient weight in kg>	
Are you of Aboriginal or Torres Strait Islander origin? 
<PtEthnicity>	
Have you ever served in the Australian Defence Force?    <Has Pt served in the Aust Defence Force?>  				
Are you a client of the Department of Veterans’ Affairs or have you received a	
benefit or support from the Department of Veterans’ Affairs?	Yes	No	
Is there a compensation case relating to this episode?		Yes	No	
(If yes, record the type of compensation): (Mark X in box)	Worker’s Compensation	
	
Public Liability	

Motor Vehicle	
	
Other ……..………………………………	

How did your main pain begin?  (Mark X in box)	
Injury at home		Motor vehicle crash		After surgery		
Injury at work/school		      Cancer		No obvious cause		
Injury in another setting	Medical condition other than cancer		Other (please specify)
……………………………………………………	
How long has your main pain been present? (Mark X in one box only)	
Less than 3 months	12 months to 2 years		More than 5 years		
3 to 12 months		2 to 5 years				

Which statement best describes your pain?        (Mark X in one box only)		
Always present (always the same intensity)		
Always present (level of pain varies)		
Often present (pain free periods last less than 6 hours)		
Occasionally present (pain occurs once to several times per day, lasting up to an hour)	
Rarely present (pain occurs every few days or weeks)		
Do you have any of the following?         (Mark X in box relevant to patient)		
A mental health condition, in particular:	PTSD	Anxiety	Depression Other (please specify) ………………………………………………………………………………………………………………………	
Arthritis (including Rheumatoid/Osteoarthritis)		
Muscle, bone and joint problems other than arthritis (including Osteoporosis, Fibromyalgia)	
Heart and circulation problems (including Heart Disease, Pacemaker, Blood Disease)
In particular specify if you have:	High Blood Pressure	High Cholesterol	
Diabetes		
Digestive problems (including IBS, GORD, Stomach Ulcers, Reflux, Bowel Disease)		
Respiratory problems (including Asthma, Lung Disease, COPD, Sleep Apnoea)		
Neurological problems (including Stroke, Epilepsy, Multiple Sclerosis, Parkinson’s Disease)	
Cancer		
Liver, kidney and pancreas problems (including Pancreatitis, Kidney Disease)		
Thyroid problems (including Hyperactive or Hypoactive Thyroid, Graves’ Disease)		
Any other medical conditions (please specify) ……………………………………………………………………………	
Health care (other than your visits to the pain clinic)		
1. How many times in the past 3 months have you seen a general practitioner in regard to your pain?	……… times	
2. How many times in the past 3 months have you seen a medical specialist (e.g. orthopaedic surgeon) in regard to your pain?	
……… times	
3. How many times in the past 3 months have you seen health professionals other than doctors (e.g. physiotherapist, chiropractor, psychologist) in regard to your pain?	
……… times	
4. How many times in the past 3 months have you visited a hospital emergency department in regard to your pain? (Include all visits, regardless of whether or not you were admitted to the hospital from the emergency department)	
……… times	
5. How many times in the past 3 months have you been admitted to hospital as an inpatient because of your pain?	
……… times	
6. How many diagnostic tests (e.g. X-rays, scans) have you had in the last 3 months relating to your pain?	
……… tests	

Section 2 – Your work	
Are you currently employed (working for pay)?	
Yes - If yes, are you:
Working full-time Working part-time
Please answer the questions below	No	- If no, are you:
(Mark X only, then go straight to Section 3)
Unable to work due to a condition other than pain
Unable to work due to pain
Not working by choice (student, retired, homemaker)
Seeking employment (I consider
myself able to work but cannot find a job)	
During the past seven days, how many hours did you miss from work because of problems associated with your pain?
(Include hours you missed on sick days, times you went in late, left early, etc. because of your pain. Do not include time you missed to attend this pain clinic).	

…………… hours	
During the past seven days, how many hours did you actually work?
(If ‘0’ skip the next question and go to Section 3)	
…………… hours	
During the past seven days, how much did your pain affect your productivity while you were working?
Think about days you were limited in the amount or kind of work you could do, days you accomplished less than you would like, or days you could not do your work as carefully as usual.

If pain affected your work only a little, choose a low number. Choose a high number if pain affected your work a great deal.

Consider only how much pain affected productivity while you were working	
Pain had no effect on my work	

0	

1	

2	

3	

        4      5	      6

Bold & underline a number relevant to patient	

7	

8	

9	

10	Pain completely prevented me from working	

Section 3 – Medication use	
Are you taking any medications?   No (please go to Section 4)
Yes (Please list all the medications you are taking. Include both prescription and over- the-counter medicines)

<SelectedRx>
	
Medicine name
(as on the label)	Medicine strength
(as on the label)	How many do you take per day?	How many days per week do you take this
medication?	

				

				

				

				

				

				

Section 4 – Pain intensity and interference	
On the diagram below, shade in ALL the areas where you feel pain.

On the diagram below, put an X on the ONE area that hurts most.

Please rate your pain by Bold & underline the one number that best describes the following:	

1. Your pain at its worst in the last week?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

No pain	

	

	
	
Pain as bad as you can imagine	

2. Your pain at its least in the last week?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

No pain	

	

	
	
Pain as bad as you can imagine	

3. Your pain on average?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

No pain	

	

	
	
Pain as bad as you can imagine	

4. How much pain do you have right now?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

No pain	

	

	
	
Pain as bad as you can imagine	

During the past week, how much has pain interfered with the following: (Bold & underline number)	

1. Your general activity?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

Does not interfere	

	

	

Completely interferes	

2. Your mood?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

Does not interfere	

	

	

Completely interferes	

3. Your walking ability?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

Does not interfere	

	

	

Completely interferes	

4. Your normal work (both outside the home and housework)?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

Does not interfere	

	

	

Completely interferes	

5. Your relations with other people?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

Does not interfere	

	

	

Completely interferes	

6. Your sleep?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

Does not interfere	

	

	

Completely interferes	

7. Your enjoyment of life?	
0	

1	

2	

3	

4	

5	

6	

7	

8	

9	

10	

Does not interfere	

	

	

Completely interferes	

Section 5 – DASS21	
Please read each statement and BOLD & UNDERLINE a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:
1	Did not apply to me at all
2	Applied to me to some degree, or some of the time
3	Applied to me to a considerable degree, or a good part of the time
4	Applied to me very much, or most of the time	
	
Not at all	Some of the time	A good part of the
time	Most of the time	
1.	I found it hard to wind down	0	1	2	3	
2.	I was aware of dryness of my mouth	0	1	2	3	
3.	I couldn’t seem to experience any positive feeling at all	0	1	2	3	
4.	I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion)	0	1	2	3	
5.	I found it difficult to work up the initiative to do things	0	1	2	3	
6.	I tended to overreact to situations	0	1	2	3	
7.	I experienced trembling (e.g. in the hands)	0	1	2	3	
8.	I felt that I was using a lot of nervous energy	0	1	2	3	
9.	I was worried about situations in which I might panic and make a fool of myself	0	1	2	3	
10. I felt that I had nothing to look forward to	0	1	2	3	
11. I found myself getting agitated	0	1	2	3	
12. I found it difficult to relax	0	1	2	3	
13. I felt down-hearted and blue	0	1	2	3	
14. I was intolerant of anything that kept me from getting on with what I was doing	0	1	2	3	
15. I felt I was close to panic	0	1	2	3	
16. I was unable to become enthusiastic about anything	0	1	2	3	
17. I felt I wasn’t worth much as a person	0	1	2	3	
18. I felt that I was rather touchy	0	1	2	3	
19. I was aware of the action of my heart in the absence of physical exertion (e.g. a sense of heart rate increase, heart missing a
beat)	
0	
1	
2	
3	
20. I felt scared without any good reason	0	1	2	3	
21. I felt that life was meaningless	0	1	2	3	

Section 6 – PSEQ	
Rate how confident you are that you can do the following things at present despite the pain. Bold & underline  the numbers on the scale under each item, where 0 = Not at all confident and 6 = Completely confident.
Remember this questionnaire is not asking whether or not you have been doing these things, but rather how confident you are that you can do them at present, despite the pain.	

1.	I can enjoy things, despite the pain	0
Not at all confident	1	2	3	4	5	6
Completely confident	
2.	I can do most of the household chores (e.g. tidying up, washing dishes, etc.) despite the pain	0
Not at all confident	1	2	3	4	5	6
Completely confident	
3.	I can socialise with my friends or family members as often as I used to do, despite the pain	0
Not at all confident	1	2	3	4	5	6
Completely confident	

4.	I can cope with my pain in most situations	0
Not at all confident	1	2	3	4	5	6
Completely confident	
5.	I can do some form of work, despite the pain (“work” includes housework, paid and unpaid work)	0
Not at all confident	1	2	3	4	5	6
Completely confident	
6.	I can still do many of the things I enjoy doing, such as hobbies or leisure activity, despite the pain	0
Not at all confident	1	2	3	4	5	6
Completely confident	

7.	I can cope with my pain without medication	0
Not at all confident	1	2	3	4	5	6
Completely confident	

8.	I can still accomplish most of my goals in life, despite the pain	0
Not at all confident	1	2	3	4	5	6
Completely confident	

9.	I can live a normal lifestyle, despite the pain	0
Not at all confident	1	2	3	4	5	6
Completely confident	

10. I can gradually become more active, despite the pain	0
Not at all confident	1	2	3	4	5	6
Completely confident	

Section 7 – PCS	
Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery.
We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.	
	Not at all	To a slight degree	To a moderate degree	To a great degree	All the time	
1.	I worry all the time about whether the pain will end	0	1	2	3	4	
2.	I feel I can’t go on	0	1	2	3	4	
3.	It’s terrible and I think it’s never going to get any better	0	1	2	3	4	
4.	It’s awful and I feel it overwhelms me	0	1	2	3	4	
5.	I feel I can’t stand it anymore	0	1	2	3	4	
6.	I become afraid that the pain will get worse	0	1	2	3	4	
7.	I keep thinking of other painful events	0	1	2	3	4	
8.	I anxiously want the pain to go away	0	1	2	3	4	
9.	I can’t seem to keep it out of my mind	0	1	2	3	4	
10. I keep thinking about how much it hurts	0	1	2	3	4	
11. I keep thinking about how badly I want the pain to stop	0	1	2	3	4	
12. There’s nothing I can do to reduce the intensity of the pain	0	1	2	3	4	
13. I wonder whether something serious may happen	0	1	2	3	4	

Thank you for completing this questionnaire

Office use only	
Medication				
Did the patient report medications?	Yes	No	
Possible differences in patient-reported medications?	Yes	No	

Tick all drug groups being taken:	
Opioids	Paracetamol	NSAIDs	Medicinal Cannabinoids	
Antidepressants	Anticonvulsants	Benzodiazepines	

Daily oral morphine equivalent	mg	
Opioid medication >2 days/week	Yes	No	
Opioid replacement/substitution program?	Yes	No	

Acknowledgements	
We acknowledge use of the following questions and assessment tools:	
•	Pain Chart: Childhood Arthritis and Rheumatology Research Alliance, www.carragroup.org von Baeyer CL et al, Pain Management, 2011;1(1):61-68	
•	Modified Brief Pain Inventory questions, reproduced with acknowledgement of the Pain Research Group, the University of Texas MD Anderson Cancer Centre	
•	Depression, Anxiety and Stress Scale, Lovibond SH & Lovibond PF (1995)	
•	Pain Self-Efficacy Questionnaire, Nicholas MK (1989)	
•	Pain Catastrophising Scale, Sullivan MJL (1995)	
•	Work productivity questions from the Work Productivity and Activity Impairment Questionnaire, Reilly MC, Zbrozek AS & Dukes EM (1993)