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Pain Treatment Outpatient Clinic Patient Interview and Examination Survey
Szanowny Panie / Szanowna Pani, prosimy o poświęcenie kilku minut na wypełnienie poniższej ankiety.
Zacząć
Zabezpieczony
Survio
Stwórz ankietę
1
Miejsce bólu
Please select the areas where you are experiencing pain
Head
Neck
Shoulders
Upper back
Lower back
Arms
Legs
2
Bóle części a/lędźwiowej b/szyjnej c/piersiowej kręgosłupa od a/... roku b/... lat c/... miesięcy d/... tygodni
Please indicate the duration of pain in the specified areas
a
b
c
d
3
Intensity of Pain
Please rate the intensity of your pain
4
Frequency of Pain
How often do you experience pain?
Daily
Weekly
Monthly
Occasionally
5
Pain Relief Methods
What methods do you use to relieve pain?
Medication
Physical therapy
Massage
Acupuncture
Heat/Cold therapy
Others
6
Impact on Daily Activities
How much does the pain affect your daily activities?
Not at all
Slightly
Moderately
Severely
7
Sleep Disturbances
Do you experience sleep disturbances due to pain?
Yes
No
8
Emotional Impact
How does pain affect your emotional well-being?
Anxious
Depressed
Irritable
Hopeless
None of the above
9
Satisfaction with Current Treatment
Are you satisfied with the current treatment for your pain?
Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
10
Additional Comments
Please provide any additional comments or concerns regarding your pain
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