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Pain Treatment Feedback Survey
Name:
*
MRN
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?
*
No difference in pain
Less than 50% improvement in your pain
50-75% improvement in pain
Over 75 % improvement in pain
Temporary flare-up in pain which then settled to a definite
improvement from the original pain by 50% or more
Pain worse and not yet settled
Have you been able to reduce your medication as a result of this?
*
Yes - Up to 50%
Yes - More than 50%
No
Have you experienced a meaningful improvement in your quality of life as a result of the treatment?
*
Yes - A significant improvement
Yes - A moderate improvement
Yes - A little improvement
No
What has improved as a result of the treatment?
Check all those that apply to you:
*
No Change
My sleep has improved
My pain has improved
My mood has improved
My fatigue has improved
I can do more physically
I have had less time off work due to pain
My family notice I am functioning better
I have been able to participate in more pleasurable activities / hobbies due to improvement
Fewer side-effects because I have a reduced requirement for painkillers
I have been able to participate more fully within my family/home life due to the improvement
Have you experienced any complications from the treatment?
*
Yes - but settled on their own
Yes - and had to see my GP or out-of-hours service
In which case please contact us to let us know about this on 0300 422 2976
No
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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