PATIENT NAME:
GENDER:
DOB:
Neuropathic Pain DATE:
Diagnostic Questionnaire TIME:
Please complete this questionnaire by ticking one answer for each item in the 4 questions below.
A “YES” score of ≥4 is diagnostic of Neuropathic Pain.
INTERVIEW OF THE PATIENT
Question 1: Does the pain have one or more of the following characteristics?
YES NO
1 - Burning
2 - Painful cold
3 - Electric Shocks
Question 2: Is the pain associated with one or more of the following symptoms in the same area?
YES NO
4 - Tingling
5 - Pins and Needles
6 - Numbness
7 - Itching
EXAMINATION OF THE PATIENT
Question 3: Is the pain located in an area where the physical examination may reveal one or more of the following characteristics?
YES NO
8 - Touch Hypoaesthesia
9 - Pricking Hypoaesthesia
Question 4: In the painful area, can the pain be caused or increased by:
YES NO
10 – Brushing (for example: using a Von Frey Hair brush)
*D. Bouhassira et al. Pain. 2005 Mar 114(1-2):29-36.
Patient Score: /10
Copyright 2005 All rights reserved
Version 1.0 - 03/05
Assessing Pain
On the diagram below, please shade in the areas where the patient feels pain.
How did the pain develop? ………………………………………………………………………………….
Pain pattern: are there specific times of the day or night when the pain is most intense?
……………………………………………………………………………………………………………………….
What level of interference does the pain present: (circle one number only)
• General activity 0 1 2 3 4 5 6 7 8 9 10
• Mood 0 1 2 3 4 5 6 7 8 9 10
• Normal work 0 1 2 3 4 5 6 7 8 9 10
• Relationship 0 1 2 3 4 5 6 7 8 9 10
• Sleep 0 1 2 3 4 5 6 7 8 9 10
• Enjoyment of life 0 1 2 3 4 5 6 7 8 9 10
0 = Does not interfere 10 = Completely interferes
What kind of things help ease the pain?………………………………………………………………………
What medication or treatment is the patient currently receiving?…………………………………….
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
How much relief has this treatment provided? (circle one number only)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
0% = No relief 100% = Complete relief
Copyright 2005 All rights reserved
Version 1.0 - 03/05
