Office use - Reason for collection:
•	Pathway start
•	Pathway end/episode end
•	Post episode review ¨ Other	Practice Name: <<Practice:Name>>	

FOLLOW-UP QUESTIONNAIRE	
Section 1 – Your details	
Title	<<Patient Demographics:Title>>	Family name (surname)
<<Patient Demographics:Surname>>	Given name(s)
<<Patient Demographics:First Name>>     <<Patient Demographics:Middle Name>>	
Gender
<<Patient Demographics:Gender>>	Date of birth (dd/mm/yyyy)
<<Patient Demographics:DOB>>	Today’s date (dd/mm/yyyy)
<<Miscellaneous:Date>>	
Height (in cm)   <<Patient Height in cm?>>	Weight (in kg)  <<Patient weight in kg>>	
Compared with before receiving treatment at this pain management service, how would you describe yourself now overall?

(Mark X next to the most relevant number on the scale)	
-3	-2	-1	0	1	2	3	
Very much worse		                  Unchanged			        Very much better	

Compared with before receiving treatment at this pain management service, how would you describe your physical abilities now?

(Circle the most relevant number on the scale)	
-3	-2	-1	0	1	 2	3	
Very much worse

		                  Unchanged			Very much better	
Which statement best describes your pain? (Mark X next to statment)	
   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)	
  Pain is no longer present	

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

Mark X under A NUMBER	

  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)

<<Clinical Details:Medication List>>
	
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 marking X under 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:	

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 circle 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. (Please bold & underline patient answer)

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. Mark X under number of 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. (Mark X under number )	
	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)	

Argus Summary:  Patient Name: <<Patient Demographics:Full Name>>    DOB: <<Patient Demographics:DOB>>   Address:<<Patient Demographics:Address>>