Pain Questionnaire for new patients

Version 5 | Updated 15th April 2026

Pain Questionnaire for New Patients

Chronic Pain Management Service

Author ID: SD / LB
Leaflet Ref: Pain 039Q
Version: 5
Leaflet title: Pain Questionnaire for new patient's (Chronic Pain Management Service)
Date Produced: July 2025
Expiry Date: July 2027

Welcome to the Chronic Pain Service at Wrightington, Wigan & Leigh NHS Teaching HospitalsFoundation Trust.

If you have difficulty with reading or writing then you should get help to fill in this questionnaire. It is possible to receive help from a community link worker at your GP practice who can help with this. If you do need this assistance, please ask your GP practice for information regarding support available.

We know that pain often affects many aspects of life such as work, leisure, sleep, friendships, mood etc. To help the team in best managing your pain and its consequences, we ask you to fill in this questionnaire about your pain and health. We run several types of clinics. The answers you have given, along with other information we have received, will help to decide the clinic which you are seen at and an appointment will be then sent out to you.

Currently we run three types of clinics: a Nurse/Physiotherapist Clinic; a Doctor Only Clinic; and a Medical Consultant/Clinical Psychologist Clinic. As part of our service we also offer a pain management group run by occupational therapy; physiotherapy and clinical psychology. Sometimes an assessment with the pain management group staff will be offered if we feel this would be most suited to your needs.

Please try to answer all the questions as best as you can.

Information about chronic pain and the service, resources to access, and treatment options available can be viewed by typing https://www.wwl.nhs.uk/our-departments?service=113 into your browser.

Name .............................................................................................................

Date of Birth ..................................................................................................

Address .........................................................................................................

........................................................................................................................

Telephone number

Home .............................................................................................................

Mobile ............................................................................................................

GP Name and Address ................................................................................

........................................................................................................................

Please indicate on the body chart the position of your pain(s) and other sensations (if any).

Please use the symbols as shown below:

Numbness	Pins & Needles	Aches	Pain
========	000000000000	xxxxxxxxx	////////////
========	000000000000	xxxxxxxxx	////////////
========	000000000000	xxxxxxxxx	////////////

A black and white of a person's body
AI-generated content may be incorrect.

1. Please tell us how long have you had the pain for?

2. Could you outline below how your pain problem started?

3. How long does a pain attack last (circle the relevant answer):

Seconds

Minutes

Hours

Days

Constant

4. Can you tell us what makes the pain worse?

5. What makes the pain better?

6. Does your pain vary during the day? When is it at its best and worst?

7. Has the pain got better or worse over time or is it much the same?

8. Have you had to give anything up because of the pain (job, friends, family commitment, social life etc.)?

9. Do you participate in any regular exercise? If so, what and how often?

10. Can you get a good night’s sleep? If not, why not?

11. Have you had any major illnesses or operations in the past?

12. Are you seeing any other specialists for your pain or other health conditions?

13. What do you believe to be the cause of your pain?

14. What do you hope to achieve by coming to the Chronic Pain Service?

Please can you tell us what treatments (apart from medication from your doctor) you have already tried for your pain, for example: operations, TENS, injections, physiotherapy, acupuncture, osteopathy, splints, corsets etc.?

Year	Type of treatment	Practitioner (e.g. surgeon, chiropractor, general practitioner)	Did it work?

Can you please list your current pain medication and tell us whether they help?

Please then list other medication you take.

Name of medicine	Dose	Number of times a day or week	Are you taking it as prescribed?	Do you think it helps?

Please tell us a little bit more about yourself. This will help us to understand how pain affects all areas of your life.

Marital status: Please tick all that apply

¨ Single ¨ Living with partner ¨Separated ¨ Married

¨ Divorced ¨ Widowed

What is your work current situation: Please tick all that apply?

¨ Employed ¨ Employed but on sick leave ¨ Unemployed

¨ Homemaker ¨ Retired ¨ Student ¨ Voluntary Worker

¨ Other (please specify): ……………………………………………………………

What is/was your job title?

Do you have any hopes/ plans to return to work in the future?

Are you receiving or in the process of claiming any state benefits? If so, please give details:

Are there any legal/insurance actions being taken with regards to your pain? Please tick one:

¨ None ¨ Anticipated ¨ Current ¨ Finished

Do you need to use aids or appliances (wheelchair, crutches, walling stick etc.) because of the pain?

If you have any comments to make, information to add, or any questions to ask, please write below.

Please now complete the following measures which will help us to further understand your pain and how this is currently affecting you:

PASS (Pain Anxiety Symptoms Scale)

Individuals who experience pain develop different ways to respond to that pain. We would like to know what you do and what you think about when in pain. Please use the rating scale below to indicate how often you engage in each of the following thoughts or activities. Circle any number from 0 (NEVER) to 5 (ALWAYS) for each item.

		Never Always
1.	I think that if my pain gets too severe it will never decrease	0	1	2	3	4	5	FT
2.	When I feel pain I am afraid that something terrible will happen	0	1	2	3	4	5	FT
3.	I go immediately to bed when I feel severe pain	0	1	2	3	4	5	A
4.	I begin trembling when engaged in activity that increases pain	0	1	2	3	4	5	PR
5	I can’t think straight when I am in pain	0	1	2	3	4	5	CA
6.	I will stop any activity as soon as I sense	0	1	2	3	4	5	A
7.	Pain seems to cause my heart to pound or race	0	1	2	3	4	5	PR
8.	As soon as pain comes on I take medication to reduce it	0	1	2	3	4	5	A
9.	When I feel pain I think that I may be seriously ill	0	1	2	3	4	5	FT
10.	During painful episodes it is difficult for me to think of anything else besides the pain	0	1	2	3	4	5	CA
11.	I avoid important activities when I hurt	0	1	2	3	4	5	A
12.	When I sense pain I feel dizzy or faint	0	1	2	3	4	5	PR
13.	Pain sensations are terrifying	0	1	2	3	4	5	FT
14.	When I hurt I think about the pain constantly	0	1	2	3	4	5	CA
15.	Pain makes me nauseous (feel sick)	0	1	2	3	4	5	PR
16.	When pain comes on strong I think I might become paralysed or more disabled	0	1	2	3	4	5	FT
17.	I find it hard to concentrate when I hurt	0	1	2	3	4	5	CA
18.	I find it difficult to calm my body down after periods of pain	0	1	2	3	4	5	PR
19.	I worry when I am in pain	0	1	2	3	4	5	CA
20.	I try to avoid activities that cause pain	0	1	2	3	4	5	A

Modified Zung

For each of these questions please indicate which answers best describe how you have been feeling recently.

	PLEASE INDICATE WITH A TICK
	Never	Now and then	Quite often	Most of the time
I feel downhearted and sad
Morning is when I feel best
I have crying spells or feel like it
I have trouble getting to sleep at night
I feel that nobody cares
I eat as much as I used to
I still enjoy sex
I notice that I am losing weight
I have trouble with constipation
My heart beats faster than usual
I get tired for no reason
My mind is as clear as it used to be
I tend to wake up too early
I find it easy to do things I used to
I am restless and can’t keep still
I feel hopeful about the future
I am more irritable than usual
I find it easy to make a decision
I feel quite guilty
I feel that I am useful and needed
My life is pretty full
I feel that others would be better off if I were dead
I still enjoy the things I used to

Short-Form McGill Pain Questionnaire

Name: ............................................................................ Date:...............................................

Please select from the list below words that you would use to describe your pain:

	NONE	MILD	MODERATE	SEVERE
Throbbing	0	1	2	3
Shooting	0	1	2	3
Stabbing	0	1	2	3
Sharp	0	1	2	3
Cramping	0	1	2	3
Gnawing	0	1	2	3
Hot-Burning	0	1	2	3
Aching	0	1	2	3
Heavy	0	1	2	3
Tender	0	1	2	3
Splitting	0	1	2	3
Tiring-Exhausting	0	1	2	3
Sickening	0	1	2	3
Fearful	0	1	2	3
Punishing-Cruel	0	1	2	3

Mark a cross on the line below to indicate the intensity of your pain:

Thank you for taking the time to complete this questionnaire. The questionnaire will now be looked at by staff members of the Chronic Pain Service, and a decision will be made on which type of appointment you will receive based on how you have responded to the questions. We will then be in contact with an appointment as soon as one is available. We look forward to meeting you.

Last modified 15th April 2026 12:56:18 pm