LOWER BACK PAIN · 2017. 11. 7. · LOWER BACK PAIN Please help us to understand exactly what you...
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( PLACE PATIENT LABEL HERE) SURNAME: ____________________________________ NHI: _____________ FIRST NAMES: ____________________________________________________ Date of Birth: _______ /_______ /_______ SEX: _____________ Emergency Medicine/Orthopaedics/Gen Med Sept 2017 LOWER BACK PAIN Please help us to understand your pain completely. Take as long as you need to fill in this form. Be as specific as you can. Once you have finished, hand the form to your nurse or the clinician who comes to see you. Your clinician will use this information to help make a full assessment. BEST CARE BUNDLE - PATIENT SELF ASSESSMENT When did you first notice the pain? What do you think the cause is for the pain? Have you had similar pain in the past? ⬜ No ⬜ Yes If yes: Please tell us about it. What treatment worked for your pain? What pain relief have you taken today? Also mention how many tablets and at what time What makes the pain worse? For example certain positions, movements or activities What makes the pain better? For example certain positions, movements or activities How bad is your pain right now? (Circle the number on the scale) 0 1 2 3 4 5 6 7 8 9 10 7.7.201 E
Transcript of LOWER BACK PAIN · 2017. 11. 7. · LOWER BACK PAIN Please help us to understand exactly what you...
(PLACE PATIENT LABEL HERE)
SURNAME: ____________________________________ NHI: _____________
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
Emergency Medicine/Orthopaedics/Gen Med Sept 2017
LOWER BACK PAINPlease help us to understand your pain completely. Take as long as you need to fill in this form. Be as specific as you can. Once you have finished, hand the form to your nurse or the clinician who comes to see you. Your clinician will use this information to help make a full assessment.
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When did you first notice the pain?
What do you think the cause is for the pain?
Have you had similar pain in the past? ⬜ ︎ No ⬜ Yes If yes: Please tell us about it. What treatment worked for your pain?
What pain relief have you taken today? Also mention how many tablets and at what time
What makes the pain worse? For example certain positions, movements or activities
What makes the pain better? For example certain positions, movements or activities
How bad is your pain right now? (Circle the number on the scale)
0 1 2 3 4 5 6 7 8 9 10
7.7.20
1E
(PLACE PATIENT LABEL HERE)
SURNAME: ____________________________________ NHI: _____________
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
Emergency Medicine/Orthopaedics/Gen Med Sept 2017
BE
ST
CA
RE
BU
ND
LE
- P
AT
IEN
T S
EL
F A
SS
ES
SM
EN
T
Do you have any areas of numbness? ⬜︎ No ⬜ Yes
Do you have any areas of pins and needles? ⬜︎ No ⬜ Yes
Please mark on the diagram where your pain is exactly Also mark areas of numbness or pins-and-needlesPlease mark on the diagram where your pain is exactly Also mark areas of numbness or pins-and-needles
LOWER BACK PAINPlease help us to understand exactly what you are feeling.
What will happen next?
• Give this form to your nurse or the clinician who comes to see you.• If you need more pain relief before then - please let your nurse or the staff behind the desk
know
Is there anything else you think we need to know about your back pain?
Your signature:__________________________
