Central Office

Pain Questionnaire

Personal Information
Pain Questionnaire
  1. Site - Where is the pain?

  2. Onset - When did the pain start. Was it sudden or gradual. Progressive or Regressive (Improving over the time)?

  3. Character - What is the pain like?










  4. Radiation - Does the pain radiate/spread out anywhere?

  5. Associations - Any other signs/symptoms associated with the pain?

  6. Time Course - Does the pain follow any pattern?





  7. Exacerbating/Triggering/Relieving factors - Does anything change the pain? Trigger or relieve?

  8. Severity - How bad is the pain (Scale from 1 to 10)

  9. Medication

  10. Medical Conditions/Allergies