Evaluate Your Chronic Pain
The following questionnaires
are used by our staff in evaluating
the effects of chronic pain on
life functioning. They are not
meant to be complete or represent
a full evaluation. They must
be interpreted by our staff to
be correctly understood. Three
questionnaires require that you
first print them, fill them out
and then fax or mail them back
to Pacifica.
Unused information sent to us
is stored for 180 days or less
and then discarded. Our staff
will contact you for discussion
within 48 hours of receipt of
documents. There is no charge
for completion of these questionnaires
or staff response to them.
All information received is
confidential and if sent
electronically is encrypted.
We follow the medical guidelines
of security and privacy formulated
by HIPAA.
These questionnaires are not
a substitute for proper medical
diagnosis or treatment. Only
your doctor can diagnose
and recommend treatment.
The Brief Evaluation includes
3 questionnaires:
| Print & Fax
Questionnaires |
Estimated
Completion
Time |
|
Tell
Us About Your
Pain |
30
minutes |
|
Pain Diagram |
5
minutes |
|
Oswestry |
10
minutes |
Click
here to start the Brief
Evaluation
The Comprehensive
Evaluation includes
these additional questionnaires:
Electronic
Questionnaires |
Estimated
Completion
Time |
|
|
Describe
Your Chronic
Pain / Pain Experience |
30
minutes |
| |
Pain Syndrome
Inventory / Stanford
Surgical |
20
minutes |
| |
Medication and
Drug Inventory |
30
minutes |
Click
here to start the Comprehensive
Evaluation
If you complete the Brief Evaluation
and decide to then do the Comprehensive
Evaluation you do not have to
repeat the first three questionnaires.
Each electronic questionnaire
must be entirely completed at
one time or it must be started
over from the beginning. The
Comprehensive Evaluation takes
about 60-80 minutes and the Brief
Evaluation takes about 30-45
minutes.
|
