New Patient Questionnaire

    Step One

    It is essential that we are able to keep your GP/registered practice informed in relation to your treatment and medication. Please ensure you fill in the required fields marked with an asterisk (*)

    GP Surgery *

    GP's Name *

    GP Phone Number *

    GP Email

    GP Fax

    Address *

    Insurance Details

    Insurance Company Name

    Insurance Company Policy Number

    Insurance Pre-authorisation code for the appointment

    Personal Details

    Name (including title) *

    Home Address *

    Daytime Landline Number*

    Daytime Mobile Number

    If you are normally a resident overseas, could you please provide us with a UK contact phone number.

    UK contact phone number:

    Date of Birth (DD/MM/YY) *

    Age *

    Your Email *

    NHS Number or equivalent (UK patients only)

    Passport or National ID Number (International patients only)

    Please advise how you found out about our clinic? *

    Step Two

    Do you have any medical illnesses? (i.e. asthma, diabetes, high blood pressure etc) *

    Are you allergic to any drugs, medicines, foods etc? If yes, please provide the name of the drug or allergen and your reaction. *

    Describe the pain

    What medication (tablets/drugs) are you currently taking?

    Site of the pain (i.e. arm, lower back, neck)

    Character of the pain (i.e. Sharp, burning, pricking, stabbing, aching, etc.). Please try and explain in your own words.

    When did the pain start?

    Is there anything that precipitated the pain? (i.e. accident, illness etc.)

    How often do you get the pain (i.e. continuous, daily, hourly etc.)

    Does the pain radiate to any other part of the body?

    What things aggravate the pain? (i.e. standing, walking etc.)

    What investigations have you had for your pain? (i.e. x rays, MRI etc.)

    Step Three

    What treatments have you had and what was their outcome? (i.e. Treatment = 2 epidurals, Outcome = effect lasted only a few weeks)

    Treatment

    Outcome

    Medication:

    Outcome

    Physiotherapy:

    Outcome

    Alternative Medicine:

    Outcome

    Nerve Blocks:

    Outcome

    Surgery:

    Outcome

    Advanced pain management techniques (i.e. spinal cord stimulator):

    Outcome

    Other Information

    Do you have any other symptoms associated with your pain? (i.e. difficulty dressing etc)

    What previous surgeries have you had? (i.e. appendix, hip replacement etc)

    Please provide any other information you feel is relevant to your case

    Step Four

    Question

    Answer

    1

    Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and toothaches). Have you had pain other than these every day kinds of pain?

    YesNo

    2

    Please tell us where you are feeling pain. E.G 'Lower back' or 'base of skull' etc. Note as many areas as needed.

    3

    Please rate your pain by number that best describes your pain at its worst in the last 24 hours. (0 - no pain / 10 – pain as bad as you can imagine)

    4

    Please rate your pain by number that best describes your pain at its least in the last 24 hours. (0 - no pain / 10 – pain as bad as you can imagine)

    5

    Please rate your pain by number that best describes your pain on the average.
    (0 - no pain / 10 – pain as bad as you can imagine)

    6

    Please rate your pain by number that tells how much pain you have right now.
    (0 - no pain / 10 – pain as bad as you can imagine)

    7

    What treatments or medications are you receiving for your pain?

    8

    In the last 24 hours, how much relief have pain treatments or medications provided? Please give a percentage that most shows how much relief you have received. (0% - no relief / 100% - complete relief)

    9

    Indicate below the one number that describes how, during the past 24 hours, pain has interfered with your:
    (0- does not interfere / 10 – completely interferes)

    A

    General activity

    B

    Mood

    C

    Walking ability

    D

    Normal work (includes both work outside the home and housework)

    E

    Relations with other people

    F

    Sleep

    G

    Enjoyment of life

    Please note, all information given on this proforma remains confidential and is held securely by London Cannabis Clinic in accordance with GDPR and the DPA 2018. The information is used to help simplify your assessment and to enable maximum time to be spent on examination and discussion during your assessment. It is no way a substitute for a full consultation and examination. Thank you for taking the time to complete this questionnaire.

    Please note that the outcome will be based on the information you have provided. Therefore, London Cannabis Clinic accepts no responsibility for advice/information given relating to any incomplete, inaccurate or incorrect information you have provided.