Section Navigation

Rate Your Pain

This self-assessment survey may be helpful in determining whether your chonic pain might be treatable with Medtronic Pain Therapies. Please remember that only your physician can determine whether you might be a good candidate for this therapy. You may want to print this completed page and take it with you when you see your physician.

  1. Less than 6 months
    6 months - 1 year
    1 - 2 years
    More than 2 years
  2. Head
    Neck
    Shoulder
    Upper arm
    Lower arm
    Hand
    Upper back
    Lower back
    Chest
    Abdomen
    Hip
    Thigh
    Lower leg
    Foot
    Other parts of my body
    All over my body
  3.      0
    1
    2
     3
    4
     5
     6
     7
     8
     9
    10
    Range from 1 to 10
    †Adapted from McCaffery M, Pasero C. Pain: Clinical Manual, 1999: p. 67, Mosby, Inc. Faces pain rating scale modified from Wong DL. Whaley & Wong’s Essentials of Pediatric Nursing, 5th ed., 1997: pp. 1215-1216, Mosby, Inc.
  4. Accident
    Hereditary
    Medical complication (eg following an operation)
    Sporting
    Stress
    Wear and tear
    Work-related
    Other
    Not Sure
  5. Arachnoiditis
    Complex regional pain syndrome (CRPS) or reflex sympathetic
          dystrophy (RSD)
    Degenerative disc disease
    Disc herniation
    Failed back syndrome
    Osteoporosis
    Pain caused by cancer
    Peripheral nerve injury
    Other
    Not Sure
  6. Never
    Once a year
    Monthly
    Weekly
    Daily

 

Last updated: 24 Apr 2009