Name: 姓名:
Contact Number: 联络号码:
Email: 电邮:
PAIN 1) Please identify the area of pain that you are experiencing: 请确认您现在所承受的疼痛部位: Whole body 全身Head 头Face 脸Ear 耳朵Nose 鼻子Jaw / Teeth /Mouth 下巴/牙齿/嘴Neck 颈项Shoulder 肩膀Arm 手臂Elbow 手肘Hand 手Finger 手指Wrist 手腕Chest 胸部Breast 乳房Abdomen / Stomach 腹部/肚子Upper back 上背部Mid back 中背部Lower back 下背部Pelvic 骨盆Hip 髋部Tailbone 尾骨Buttocks 臀部Thigh 大腿Knee 膝盖Shin 胫Calf 小腿Ankle 脚踝Heel 脚跟Foot 脚Toe 脚指Groin 腹股沟Genital 生殖器Anal 肛门
2) When did your pain first start? 您的疼痛最初是什么时候开始？
3) How did your pain begin? 您的疼痛怎么开始？
CHARACTERISTICS 4) Choose words that best describe your pain: 请选择最能描述您疼痛的词语: Pulsing 脉动Throbbing 悸动Pounding 重击Electric shooting 触电Stabbing 刺痛Sharp 尖锐Splitting 撕裂Cutting 切割Drilling 钻痛Piercing 冲孔Pinching 捏Pressing 压Cramping 抽筋Burning 烧Cold 冷冰Tingling / Pins and Needles 针刺Numb 麻痹Itchy 痒Stinging 蜇痛Pulling 拉Stiff 僵硬Tight 紧Tiring 累Dull 隐隐作痛Sore 酸Aching 酸痛Heavy 沉重Nagging 唠叨Squeezing 挤压Spasm 痉挛Radiating蔓延Bloating 胀
AGGRAVATING FACTORS 5a) What makes your pain worse? (You may select more than one) 以下哪些描述导致您的疼痛变得更糟？(可以选择多项） Sitting 坐Standing 站Walking 行走Exercise 运动Lying down 躺下Lifting arms / legs 举起手/脚Carrying heavy load 提重物Bending forwards / backwards 弯前 /弯后Going up/down stairs or slope 上下楼梯/ 上下斜坡Household chores 做家务Any movement任何动作Loud noise 极大的声音Cold weather 寒冷天气Hot weather 炎热天气Wet weather 潮湿天气Stress 压力Tension 紧张Driving 开车Sexual intercourse 性交No clear reason 没原因
5b) Other reasons that make your pain worse. (please describe) 其他可能导致您疼痛恶化的原因。（请描述）
RELIEF 6a) What makes your pain better? (You may select more than one) 以下哪些描述舒缓您的疼痛？（可以选择多项） Sitting 坐Standing 站Walking 行走Lying down 躺下Lifting arms / legs 举起手/脚Bending forwards / backwards 弯前/弯后Exercise 运动Stretching 伸展Changing posture from time to time 切换姿势Keeping busy 保持忙碌Relaxing / Rest 放松 / 休息Sleeping 睡觉Cold bath 冷水澡Warm/hot bath 热水澡Massage 按摩Applying pressure 施加压力Applying muscle patch / ointment 肌肉贴布 / 软膏Medications 药物Not moving 不移动No clear reason 没原因
6b) Other reasons that make your pain better. (please describe) 其他可能帮助舒缓您疼痛的原因。（请描述）
PAIN SCORE 7) How would you rate your pain level between 0-10 now? (10 being the worst pain) 目前，您如何从0-10分来评估您的疼痛指数？（10分是强烈的疼痛）
8) How would you rate your strongest pain between 0-10 for the past 1 month? 过去一个月，以0-10分来评估，您最强烈的疼痛指数是多少？
MEDICAL HISTORY/TREATMENT FOR PAIN RECEIVED 9) List by year (starting at childhood) all medical illness and operations you have had (if any). 按年份（从儿时开始）列出您有过的所有生理疾病和手术。
MEDICATION 10) Please list all the medications that you are taking currently. 请列出您目前服用的所有药物。
SLEEP 11) Do you have difficulty falling asleep? 你是否会有困难入眠？
12) Do you have difficulty staying asleep? 你是否有间断的睡眠？
13) Are you a frequent dreamer? 您经常做梦吗？
14) I do not feel refreshed despite sleeping 6-8hours, hence affecting my energy level. 尽管我已睡了6到8个小时，但仍觉得疲惫提不起精神并且影响我的活力。
EXERCISE 15) What kind of exercises have you been doing? 您经常做什么运动？
Thank you for completing this questionnaire to let us better understand your pain. 感谢您回答此疼痛问卷，让我们更了解您的疼痛状况。 We respect and keep your data safe. 我们尊重并保证您的个人资料安全。
In accordance with the Personal Data Protection Act (PDPA) of Singapore, 根据新加坡个人资料保护法 （PDPA), *
I consent to the sharing of my medical records within Singapore Paincare Center as well as other healthcare providers for any investigations, treatments and other healthcare purposes if necessary. (E.g. Hospitals, Imaging Centers, Physiotherapy Centers, etc.)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 Please refer to our privacy policy: privacy-statement.
I consent to receive marketing updates and educational information from Singapore Paincare Center.我同意接收新加坡疼痛护理中心的营销材料，包括相关活动的更新动态和教育信息
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