Current Complaint, Injury and Pain Questionnaire IN NJ

Kenneth Vercammen represents persons injured due to the negligence of others.
CURRENT COMPLAINT, INJURY AND PAIN QUESTIONNAIRE
Your Name: ______________________________ Date: ___________
1. Describe the accident or circumstances which led up to your injury
and resulting pain.
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2. When and where did you first become aware of the pain
associated with the injury? _____________________________________
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3. In what part or parts of your body does the pain first occur?
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4. In what part or parts of your body does the pain now occur?
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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).
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7. Are there any circumstances which either intensify or lessen the
pain? _____ If so, please describe in detail. _______________________
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8. Does the pain lead to any other difficulties (e.g., inability to move
your arms or legs, headaches, nausea, irritability)? _____ If so, explain.
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9. Does the pain ever interfere with your daily activities? _____ If so,
please explain in detail.
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10. Do you ever have to stop your activities to alleviate the pain? _____
If so, please explain.
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11. Do you ever have to lie down and rest to alleviate the pain? ________
If so, please explain when and how often.
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12. Do you ever have to take off from work because of the pain?________ If
so, please explain how often this happens.
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13. Has anything helped to lessen the pain (e.g. medication, relaxation,
massage, rest, counseling)?
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14. If so, how long does it take for these remedies to work?
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15. How long do these remedies last before the pain returns?
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16. What have you told your doctor about your pain? ________________
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17. Has any doctor ever told you that you are imagining your pain?____ How
did you feel when you were told?
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What did you say in response? __________________________________
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18. Has any doctor told you the cause of your pain? ____ If so, what did
he say? ___________________________________________________
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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?
____________________________________________________________________________
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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).
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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.
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22. Have you had any operations for your pain? _____ If so, please list
dates of operations.
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23. Did any of the operations help? _____ If so, which ones, and how long
did they help? ______________________________________________
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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.
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25. Do any of these medications alleviate your pain? _____ If so, specify
which ones work and for how long each works.
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26. Have you ever had any nerve blocks for pain? _____ If so, give the
dates. ____________________________________________________
27. Did any of these infections bring relief? _______________________
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28. Who prescribed the nerve blocks? ____________________________
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29. Have you ever used a TENS unit for pain? ____ If so, who
prescribed it for you? ________________________________________
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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.
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33. Did you consider yourself a "sickly" person? _____
34. What is your current treatment? _____________________________
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35. What do you expect from your treatment? ______________________
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36. Do you think your treatment plan is working? _____

37. Do you think your treatment plan is helping to alleviate your pain?
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38. Are you satisfied with your doctors and your treatment plan? _____
If not, what changes would you like to make?
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39. Have you ever had any psychological treatment for your pain? _____ If
so, when and from whom? ____________________________________
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40. Have you ever had any psychological treatment for any other condition
or problem? _____ If so, when and from whom?
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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.
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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?
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44. Do you have any desire to participate in social or recreational
activities? _____ If not, why don't you have the desire?
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45. Has the pain and injury affected your sexual activities? _____
If so, please explain. _____________________________________
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46. Does talking about your pain and injury help in any way? _____
If so, please explain. _________________________________________
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47. Are you receiving any counseling for your pain? _____ If so, from
whom? ____________________________________________________
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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. ______________________________
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52. How does your spouse react to the pain? _______________________
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53. How do your children react to the pain? _______________________
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54. How do your friends react to the pain? ________________________
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55. What was your general outlook on life before the injury and pain?
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56. What is your general outlook on life now? ______________________
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57. Do you ever feel that your situation is hopeless? _____ If so, what do
you think can be done to remedy this feeling?
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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?
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59. What do you think is the cause of your pain? ____________________
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60. What do you feel can be done to alleviate your pain? ______________
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61. What do you feel that your attorney can do to help?
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62. With respect to your pain and injury, what do you expect from your
attorney in this case? ________________________________________
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