Begin your chronic pain evaluation
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.
|
