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Home Pain Treatment Feedback Survey
Name: *
Date Of Birth: *
Postcode: *
Email Address: *
Phone Number: *
What was the date of your treatment? *
Name of your Pain Consultant: *

What happened to your pain after the treatment? *

      improvement from the original pain by 50% or more

Have you been able to reduce your medication as a result of this? *

Have you experienced a meaningful improvement in your quality of life as a result of the treatment? *

What has improved as a result of the treatment?
Check all those that apply to you: *

Have you experienced any complications from the treatment? *

In which case please contact us to let us know about this on 0300 422 2976

Thank you for filling in this feedback form. The team will organise follow up if this is required according to the plan made by your Pain Consultant.
Please rate your experience of your treatment under the chronic pain team overall: *
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