Melbourne Neurosurgeon Your Practice Online
LocationLocationsLocation(613) 9429 6262
A + - A
Dr. Graeme Brazenor - Neuro Surgeon - Director of Epworth Neurosciences Clinical Institute
View Profile
 
Home

Pain Assessment Tool for Patients

Please fill out this form and send it to us at least 2 working days before your first appointment with us.

YOUR DETAILS
* *
*
* *


INSURANCE DETAILS

Insurance Type *:  



YOUR CURRENT PROBLEM






PAIN SCALE
Using the diagram below, click on the crayon which best represents your pain and hold your mouse button to draw on the affected area of the body.

 

 



 



TREATMENTS




IMPORTANT INFORMATION : Please Click on either Yes or No.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No



PLEASE CLICK IF YOU HAVE HAD ANY OF THE FOLLOWING PROBLEMS:
High blood pressure Asthma Cancer of any type
Depression Heart surgery Sleep Apnoea
Radiotherapy Reflux Angina
Diabetes Type 2 Chemotherapy Migraine
Heart attack/s Diabetes Type 1 Long standing infections
Liver problems Cardiac stent/s DVT blood clots
Hepatitis Kidney problems Strokes
Siezures / Fits Abdominal surgery Gastric ulcers


MEDICATIONS:
Enter Medication here


INVESTIGATIONS:

Please click on any investigations that you have had:

Xrays
CT scan
MRI scan
Nerve conduction study
Bone scan
Spinal Injections
Discogram
Myelogram
Ultrasound
Other

Yes No
Yes No

Enter the code as it is shown : *
Royal Australasian College of Surgeons Spine Society of Australia
© Dr Graeme Brazenor Consulting Neurosurgeon VIC Australia