Pain Survey
The following questionnaire will help your doctor identify your level of pain. Simply print out the results and hand them to your doctor.
Q1. How long have you been experiencing pain?
Select one of the following:
Q2. Mark the place/s on the diagram where you are experiencing pain.
Q3. Choose the best way to describe your pain.
Select one of the following:
Q4. What are you currently using to treat the pain?
Select all that apply:
Q5. Are you experiencing constipation (difficulty passing a bowel motion) as a result of any pain medications you're taking?
Q7. Select gender
Select your gender by clicking on the symbol below and next to proceed:
Congratulations, you have finished the survey.
You may like to view or print your survey results and show them to your doctor.
Pain Survey
PainMedicinesAndConstipation.com.au
The following questionnaire will help in assessing your current condition.
Please give these results to your doctor.
Your Responses:
- Q1. How long have you been experiencing pain?
- Q2. Mark the place/s on the diagram where you are experiencing pain.
- Q3. Choose the best way to describe your pain.
- Q4. What are you currently using to treat the pain?
- Q5. Are you experiencing constipation (difficulty passing a bowel motion) as a result of any pain medications you're taking?
- Q6. How old are you?
- Q7. Select gender