Tell us about your pain
This assessment was created by our team of experts to help patients manage chronic pain, anxiety and other symptoms which have not responded to medication.

The results from this questionnaire will be analysed by our medical team and a team member will contact you with advice on how you can manage your symptoms.
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Email *
Name and surname *
ID card number / Passport Number
Mobile number *
Gender
Clear selection
Age *
Weight in kg
Height in cm
Occupation
Relationship status
Clear selection
Have you been diagnosed with a chronic illness?
Do you have any history of the following?
What investigations have been done so far?
Which of the following symptoms do you experience?
When did the pain start?
Clear selection
Where is the pain located?
How would you describe your pain?
How does the pain vary?
What factors worsen your pain?
What helps you ease your pain?
What helps you ease your pain the most?
How severe was your baseline pain in the last 4 weeks?
No pain
Severe pain
Clear selection
How much did the pain affect your quality of life in the last 4 weeks?
Not at all
Very much
Clear selection
Rate  your quality of sleep over the last 4 weeks
Very bad
Excellent
Clear selection
Rate  your mood over the last 4 weeks
Depressed
Happy
Clear selection
Rate your anxiety over the last 4 weeks
No anxiety
Very anxious
Clear selection
Rate your energy levels over the last 4 weeks
Very fatigued
Full of energy
Clear selection
How much does the pain affect your job / daily activities?
Not at all
Very much
Clear selection
Did you have trouble with light physical activities over the last 4 weeks?
Not at all
Very much
Clear selection
Did you have trouble with strenuous physical activities over the last 4 weeks?
Not at all
Very much
Clear selection
How much did the pain restrict your social activities over the last 4 weeks?
Not at all
Very much
Clear selection
Rate your bowel function over the last 4 weeks?
Very bad (gas/bloating/loose stools)
Very good & regular
Clear selection
Do you consume the following food products?
What exercise do you do regularly?
What stretching do you do regularly?
What meditation do you do regularly?
What vitamins / supplements do you take regularly?
What type of medications do you take regularly?
List your regular medications
Do you use any of the following substances regularly?
Further comments / notes / information
Would you like advice on how to manage your pain? 
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