Name: 姓名: NRIC No: 身份证号码: Contact No: 联络号码: 1. Please describe the pain problem that brings you to the clinic. 请描述让您前来诊所看病的病痛问题 Whole Body Pain – 全身疼Head Pain – 头疼Face Pain – 脸疼Jaw Pain - 下巴疼痛Ear Pain – 耳朵痛Nose Pain – 鼻痛Neck Pain – 脖子疼Shoulder Pain – 肩膀疼Arm Pain – 手臂疼痛Elbow Pain – 肘部疼痛Hand Pain – 手疼Back Pain – 背疼Waist Pain – 腰痛Hip Pain – 髋痛Tail Bone Pain – 尾骨疼痛Buttock Pain – 臀部疼痛Thigh Pain – 大腿疼痛Knee Pain – 膝关节疼痛Shin Pain – 胫骨疼痛Calf Pain – 小腿疼痛Feet Pain – 脚痛Chest Pain – 胸痛Breast Pain – 乳房疼痛Ankle Pain – 踝关节疼痛Pelvic Pain – 盆腔疼痛Leg Pain – 腿痛Genital Pain – 外阴痛Anal Pain – 肛门疼痛 2. When did your pain first started? 您的疼痛最初是什么时候开始的？ 3. How did your pain begin? 您的疼痛是如何开始的? 4. List by year (starting at childhood) all medical illness and operations you have had since childhood. 按年份（从儿时开始）列出您从儿时开始就有过的所有生理疾病和手术。 5. Please list all the medications you are taking at present: 请列出您目前服用的所有药物： 6. Please list all the medications you have taken in the past for your pain. 请列出您过去为减轻疼痛而服用的所有药物 7. Please list any allergies you may have and reaction related to it. 请列出您可能有的任何过敏症以及相关反应 8. Which statement best describes your pain? (if none is exactly like your pain, please tick closest statement). 哪项陈述最能描述您的疼痛？（若没有一项与您的疼痛一致，请勾选最相近的陈述） Always present – 频繁发作Usually present, but have short periods without pain – 常常发作，但有时短期内无疼痛Often present, but have pain free period lasting up to several hours – 经常发作，但有时长达几个小时无疼痛Occasionally present for brief periods – 偶尔发作, 疼痛短暂Rarely present – 很少 9. What makes your pain worse? (You may select more than one) 哪些因素恶化了您的疼痛？（可以选择多项） Sitting – 坐Standing – 站Lying down – 躺着Lifting – 抬手Bending – 弯腰No clear reason – 无明确原因Household chores – 做家务Everything – 全部Loud noise – 噪声Working – 工作Any movement – 任何 动作Cold weather – 冷天气Hot weather – 热天气Wet weather – 潮湿天气Weather changes – 天气转变Walking – 走路Computer – 看电脑Sex – 性爱Stress – 压力Tension – 紧张Driving – 驾车Going up/down stairs – 上/下阶梯None of the above – 以上都不是 Other reasons that make your pain worst (please describe) 其它可能导致您的疼痛恶化的原因（请描述） 10. What makes your pain better? (you may select more than one) 哪些因素使您的疼痛缓解？（可以选择多项） Sitting – 坐Standing – 站Lying down – 躺着Stretching – 伸展Relaxing – 放松Reading – 看书Sleep – 睡觉Watching TV – 看电视Working – 工作Warm/hot bath – 热水澡Warm/hot shower – 热水淋浴Tablets – 平板电脑Hot/cold packs – 热敷/冷敷Cold weather – 冷天气Hot weather – 热天气Pressure – 压力Massage/rubbing – 按摩Walking – 走路Keeping busy – 保持忙碌Sex – 性爱Alcohol – 喝酒Rest – 休息Nothing – 无所事事Being with other people – 与他人相处时Keeping my mind off pain – 转移对疼痛的注意力None of the above – 以上都不是 11. Other reasons that make your pain better (please describe) 其它可能导致您的疼痛缓解的原因（请描述） 12. Please rate your pain by marking the box beside the number that tells us how much pain you have right now. (0 least, 10 most) 目前，您的疼痛强度如何?（给出从1-10的数字） 012345678910 13. Please rate by marking the box beside the number that describe how the pain has interfered your walking ability during the past 24 hours. (0 least, 10 most) 在过去的 24 小时，疼痛对于您行走功能所造成的影响？(给出从1-10的数字) 012345678910 14. Please rate your pain by marking the box besides the number that best describes your pain at its worst in the last 1 week. (0 least, 10 most) 在过去一周中，您的疼痛的最高程度如何？（给出从1-10的数字） 012345678910 15. Please rate your pain by marking the Box besides the number that best describes your pain at its least in the last 1 week. (0 least, 10 most) 在过去一周中，您的疼痛的最低程度如何？（给出从1-10的数字） 012345678910 16. Please rate your pain by marking the box beside the number that best describes your pain on the average. (0 least, 10 most) 过去一周中，您的疼痛程度通常如何？（给出从1-10的数字） 012345678910 17. Choose the WORDS that best describes your pain. 选择最能描述您的疼痛的词语. A Flickering – 闪烁Quivering – 颤抖Pulsing – 脉动Throbbing – 悸动Beating – 跳动Pounding – 重击 B Jumping – 跳Flashing – 闪光Shooting – 射击 C Pricking – 刺痛Boring – 无聊Drilling – 钻孔Stabbing – 刺Lacinating – 抽痛 D Sharp – 尖锐Cutting – 切割Lacerating – 划破 E Pinching – 捏Pressing – 压制Gnawing – 咬Cramping – 抽搐Crushing – 压碎 F Tugging – 揪着Pulling – 拉Wrenching – 扭 G Hot – 热Burning – 燃烧Scalding – 烫伤Searing – 灼热 H Tingling – 麻Itchy – 痒Smarting – 痛苦Stinging – 刺痛 I Dull – 枯燥Sore – 疮Hurting – 伤害Aching – 疼痛Heavy – 沉重 J Tender – 细嫩Taut – 拉紧Rasping – 刮Splitting – 分裂 K Tiring – 累Exhausting – 辛苦 L Sickening – 令人作呕Suffocating – 窒息 M Fearful – 可怕Frightful – 吓人Terrifying – 惊恐 N Punishing – 惩罚Grueling – 严罚Cruel – 残忍Vicious – 恶毒 O Wretched – 凄惨Blinded – 盲 P Annoying – 恼人的Troublesome – 麻烦Miserable – 悲惨Intense – 激烈 Q Spreading – 传播Radiating – 散热Penetrating – 透彻Piercing – 冲孔 R Tight – 紧Numb – 麻木Drawing – 拉Squeezing – 挤压Tearing – 撕裂 S Cool – 凉爽Cold – 冷Freezing – 冷冻 T Nagging – 唠叨Nauseating – 作呕的Agonizing – 惨痛Dreadful – 可怕Stiff – 僵硬 18. If your pain could be reduced, but not completely, how much of reduction would there need to be for you to feel you could live with it? 若能够减缓您的疼痛，但不能完全去除，那么，您觉得需要减缓多少才能达到您的容忍范围？ 20%40%50%60%70%80%90%100% 19. Are there any questions you would like to be answered after your assessment at this pain clinic? 在这家疼痛诊所评估后，您还有任何需要解答的问题吗？ 20. Who can we thank for this referral? Where did you find out about our services? 对于此次的推荐,我们应该感谢谁？ 您是在哪里找到我们的服务的？ Newspaper/TV/Radio – 报纸 / 电视 / 广播Friends/relatives – 亲戚朋友Internet – 网络Magazine – 杂志Doctor’s Referral – 医生转诊Walk in – 亲临Seminar - 讲座 Thank You for completing this questionnaire to let us better understand your pain. 感谢您回答此疼痛问卷，让我们更了解您的痛。 We respect and keep your data safe. In accordance with the Personal Data Protection Act (PDPA) of Singapore, I consent the sharing of my medical records within Singapore Paincare Center as well as other health care providers for any investigations, treatments and other healthcare purposes if necessary. (Examples: Hospitals, Imaging Centers, Physio Centers, etc) I consent the usage of my medical records to be used for testimonies sharing for our marketing purposes if necessary 我们尊重并保证您的个人资料安全。 根据新加坡个人资料保护法（PDPA）, 我同意与新加坡疼痛护理中心以及其他医疗保健提供者共享我的医疗记录，以便在必要时进行任何检查，治疗或用于其他医疗保健的目的。（例如：医院，扫描中心，物理治疗中心等） 我同意新加坡疼痛护理中心,如有必要,将我的医疗记录作为见证，用于营销的目的。
