CURRENT COMPLAINT, INJURY AND PAIN QUESTIONNAIRE

Your Name: ______________________________ Date: ___________
1. Describe the accident or circumstances which led up to your injury
and resulting pain.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


2. When and where did you first become aware of the pain
associated with the injury? _____________________________________
___________________________________________________________


3. In what part or parts of your body does the pain first occur?
___________________________________________________________


4. In what part or parts of your body does the pain now occur?
___________________________________________________________


5. Has the pain ever been localized? ____ If so, where? ______________


6. Describe as best you can how the pain feels to you (include in your
answer the severity of the pain, whether the pain is continuous or
intermittent, how long it lasts, and whether it ever changes).
___________________________________________________________
___________________________________________________________


7. Are there any circumstances which either intensify or lessen the
pain? _____ If so, please describe in detail. _______________________
____________________________________________________________________________
____________________________________________________________________________
______________________

8. Does the pain lead to any other difficulties (e.g., inability to move
your arms or legs, headaches, nausea, irritability)? _____ If so, explain.
__________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
______________________


9. Does the pain ever interfere with your daily activities? _____ If so,
please explain in detail.
____________________________________________________________________________
____________________________________________________________________________
______________________


10. Do you ever have to stop your activities to alleviate the pain? _____
If so, please explain.
__________________________________________________________


11. Do you ever have to lie down and rest to alleviate the pain? ________
If so, please explain when and how often.
__________________________________________________________

12. Do you ever have to take off from work because of the pain?________ If
so, please explain how often this happens.
____________________________________________________________________________
________________________________________


13. Has anything helped to lessen the pain (e.g. medication, relaxation,
massage, rest, counseling)?
__________________________________________________________
__________________________________________________________


14. If so, how long does it take for these remedies to work?
__________________________________________________________


15. How long do these remedies last before the pain returns?
__________________________________________________________


16. What have you told your doctor about your pain? ________________
____________________________________________________________________________
________________________________________


17. Has any doctor ever told you that you are imagining your pain?____ How
did you feel when you were told?
__________________________________________________________
What did you say in response? __________________________________
____________________________________________________________________________
________________________________________

18. Has any doctor told you the cause of your pain? ____ If so, what did
he say? ___________________________________________________
__________________________________________________________


19. Are you satisfied with the doctor's explanations, or do you think the
pain is due to some cause or reason other than what the doctor has told you?
____________________________________________________________________________
________________________________________


20. List all persons you have consulted for treatment of your pain and
injury. If any of these persons are doctors, specify their specialties
(e.g., cardiologist, internist, neurologist, orthopedist, chiropractor,
osteopath, psychologist, plastic surgeon).
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
______________________________________________________________


21. Has any doctor recommended an operation to alleviate the pain? ____ If
so, please state the doctor's name and address, and when the recommendation
was made.
____________________________________________________________________________
____________________________________________________________________________
______________________


22. Have you had any operations for your pain? _____ If so, please list
dates of operations.
____________________________________________________________________________
____________________________________________________________________________
______________________

23. Did any of the operations help? _____ If so, which ones, and how long
did they help? ______________________________________________
____________________________________________________________________________
________________________________________


24. List all medications (both prescription and non-prescription) which you
are taking; include the name of the medication, its dosage, and how often
you take it.
____________________________________________________________________________
____________________________________________________________________________
______________________

25. Do any of these medications alleviate your pain? _____ If so, specify
which ones work and for how long each works.
____________________________________________________________________________
____________________________________________________________________________
______________________


26. Have you ever had any nerve blocks for pain? _____ If so, give the
dates. ____________________________________________________

27. Did any of these infections bring relief? _______________________
__________________________________________________________


28. Who prescribed the nerve blocks? ____________________________
__________________________________________________________


29. Have you ever used a TENS unit for pain? ____ If so, who
prescribed it for you? ________________________________________
__________________________________________________________


30. Did the TENS unit provide relief? ____________________________

31. Prior to this injury, did you ever experience any severe pain over a
period of time? _____________________________________________

32. If so, please give the circumstances and dates.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____


33. Did you consider yourself a "sickly" person? _____

34. What is your current treatment? _____________________________
____________________________________________________________________________
____________________________________________________________________________
______________________


35. What do you expect from your treatment? ______________________
____________________________________________________________________________
________________________________________


36. Do you think your treatment plan is working? _____


37. Do you think your treatment plan is helping to alleviate your pain?
__________________________________________________________


38. Are you satisfied with your doctors and your treatment plan? _____
If not, what changes would you like to make?
____________________________________________________________________________
________________________________________


39. Have you ever had any psychological treatment for your pain? _____ If
so, when and from whom? ____________________________________
____________________________________________________________________________
________________________________________


40. Have you ever had any psychological treatment for any other condition
or problem? _____ If so, when and from whom?
____________________________________________________________________________
________________________________________

41. Has the pain interfered with your social life? _____ If so, be as
specific as possible in describing any activities or hobbies in which you
can no longer participate or which you can no longer enjoy.
____________________________________________________________________________
________________________________________

42. Did you consider yourself an active and energetic person before your
injury and the resulting pain? _____

43. Are there any activities or hobbies you still enjoy? _____ What are
they and to what extent can you still participate in them?
____________________________________________________________________________
____________________________________________________________________________
______________________


44. Do you have any desire to participate in social or recreational
activities? _____ If not, why don't you have the desire?
____________________________________________________________________________
____________________________________________________________________________
______________________

45. Has the pain and injury affected your sexual activities? _____
If so, please explain. _____________________________________
____________________________________________________________________________
____________________________________________________________________________
______________________

46. Does talking about your pain and injury help in any way? _____
If so, please explain. _________________________________________
____________________________________________________________________________
____________________________________________________________________________
______________________

47. Are you receiving any counseling for your pain? _____ If so, from
whom? ____________________________________________________
____________________________________________________________________________
________________________________________


48. Do you consider yourself to be an irritable and impatient person?
_____

49. How often do you get angry? ________________________________

50. Do you feel that your anger or irritability is associated with your
pain? _____________________________________________________

51. Do you feel that your pain is causing you to have emotional
difficulties? _____ If so, explain. ______________________________
__________________________________________________________


52. How does your spouse react to the pain? _______________________
____________________________________________________________________________
________________________________________

53. How do your children react to the pain? _______________________
____________________________________________________________________________
________________________________________


54. How do your friends react to the pain? ________________________
____________________________________________________________________________
_______________________________________


55. What was your general outlook on life before the injury and pain?
__________________________________________________________
____________________________________________________________________________
________________________________________

56. What is your general outlook on life now? ______________________
____________________________________________________________________________
________________________________________

57. Do you ever feel that your situation is hopeless? _____ If so, what do
you think can be done to remedy this feeling?
_______________________________________________________________________


58. Do you consider that you have a positive outlook with respect to your
injury and pain? _____ If not, what can you do or what can be done to
achieve a positive outlook?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____

59. What do you think is the cause of your pain? ____________________
____________________________________________________________________________
________________________________________

60. What do you feel can be done to alleviate your pain? ______________
____________________________________________________________________________
________________________________________

61. What do you feel that your attorney can do to help?
__________________________________________________________
__________________________________________________________

62. With respect to your pain and injury, what do you expect from your
attorney in this case? ________________________________________
____________________________________________________________________________
____________________________________________________________________________