How to fill this form?

Item number 1-6: Your personal details. This is required for contacting you in
different situations like: change of appointment time and/or date, cancelling
appointment in emergency situation, availability of experts from other city/country
for free consultation etc.
Item number 7: You should mention duration of sufferings. You may write the whole
duration of pain and specify duration (or date if you remember it) when the pain has
started to worsen.
Item number 8-10: We should have some idea about the quantity or amount of pain.
This is a simple numerical tool to assess pain. First you should imagine the
maximum pain you can tolerate. This is totally imaginary, not your present & actual
pain. One will die out of pain if pain is increased slightly more than this this
maximum pain (out of shock). This maximum imaginary pain = 10. So there can not
have pain of 10.1 or 11 according to this scale. If there is no pain, then the score will
be 0. So your actual or real pain must lie somewhere between 0 to 10. In item
number 8, put your present pain. In item number 9, the maximum pain you felt in
last one month and in item number 10, you should make an average of all pain you
felt over last one month.
Item number 11. Here we want to know the pattern of pain over 24 hours. Cross box
1. if your pain remains same throughout the day without any fluctuation (increase or
decrease of pain). Cross box 2. if your pain comes suddenly and there is no pain in
between these attacks of pain. Cross box 3. if there are sudden severe attacks of
pain with a constant baseline residual pain. In other words, there is always some
amount of pain with increase of pain at times. Cross box 4. if baseline pain is
minimal as well as pain attacks. This is same as box 3. only in mild form.
Item number 12: Put yes, if your pain starts from one part and spreads or radiates
to other parts of body. Put no, if pain is not moving or spreading and remaining
constantly at same position.
Item number 13: With a pen or pencil mark area or areas of pain on the pictures.
Item number 14: This box with seven questions are to identify quality or nature of
pain. Carefully read all questions, understand its meaning and put mark in
appropriate box. Mark only once for each question which can best explains your
sufferings.
Item number 15: We want to know if you have any other complains or symptoms or
sufferings other than pain. Item number 16: Most pain fluctuates throughout the
day and night. Tell us the time when you feel maximum pain in a day. If your pain is
constant (very rare) write "constant pain without fluctuations".
Item number 17: Read the different patterns of sleep described below. Mark which
explains your sleep best.
Item number 18: Intensity of pain usually changes with change of posture of body.
Mark the posture/s which increases your pain; it may be more than one.
Item number 19: Write the name of medicines you have take for pain. Even you may
bring the strips of medicine for our check up.
Item number 20: Mark accordingly.

Item number 21: Name of the disease/s you are suffering or you have suffered in
past. Mention if you feel that it might have some relevance with your present pain.
Item number 22: If you have suffered from any injury/ accident please mention it.
Mention date and injured body part.
Item number 23: Mention all operations with dates. If you have been operated for
pain, mention any change of quality, quantity and distribution of pain before and
after surgery.
Item number 24: Here we want to see the impact of pain in your mind. Read the box
carefully and cross only once for each questions.
Relax, take time and think before filling this form. Filling this form will help us to
diagnose your condition in a better way. If you have any doubts/questions in filling
this form ask us on 033-65361629 (11AM - 5PM). If it is still not clear you may keep
that part blank. But you must bring at least partially filled form before you
visit us for consultation.