Today’s date:

Patient Information

Patient name:

Age:

Sex:

Pain Description and History

Where do you experience pain?

On a 0-to-10 scale, where 0 is “No pain” and 10 is “Pain as bad as you can imagine,” how would you rate your average pain intensity in the past week? At its least in the past week? At its worst in the past week?

How important is decreasing your daily average pain intensity to you? If this is important, and if we are unable to decrease the intensity to “0,” what level of average pain intensity could you live more comfortably with?

How important is it to you to learn skills that might reduce your experience of pain

intensity (and how much the pain bothers you) for short periods of time?

What words would you use to describe your pain?

When did the pain begin?

What else was happening in your life?

Course of pain since onset:

Mark P. JensenHypnosis for Chronic Pain Management: Pain Evaluation Form. Copyright © 2011 by Oxford University Press

Oxford Clinical Psychology | Oxford University Press

Pain Evaluation Form

Course of pain in the past six months:

What treatments have you tried or been given for pain (including surgeries, passive physical therapy, active physical therapy, medications)? Which of these were helpful? Which of these made the problem worse?

What is the usual daily time course of the pain?

What makes your pain worse?

What makes your pain better?

What do you do for exercise (how much, how often)?

Some people with pain tell me that they get so tired of being inactive that on days that they feel even a little better, they try and do too much, only to pay for this with a big increase in pain. Then they have to rest, sometimes for days. Does this ever happen to you?

How do the people you live or spend time with know when you are hurting? What do you do or say?

How do the people you live or spend time with respond when they think you are hurting? What do they do or say?

How do the people you live or spend time with know when you are doing particularly well? What do you do or say?

How do the people you live or spend time with respond when you are doing well? What do they do or say?

Comparing your life now to your life before the pain, what have you stopped doing completely that you used to do? Which of these activities would you like to do again?

Comparing your life now to your life before the pain, what are you doing less of that you used to do more of? Which of these activities would you like start doing more of again?

Mark P. JensenHypnosis for Chronic Pain Management: Pain Evaluation Form. Copyright © 2011 by Oxford University Press

Oxford Clinical Psychology | Oxford University Press

Comparing your life now to your life before the pain, what are you doing more of

that

you used to not do or do much less of? Which of these activities would you like to do less of?

What do you do now to cope with the pain (if medications, what ones, and at

what doses)? How well do these coping strategies work for you?

What have you been told is the cause of your pain? What do you think about this?

What effects, if any, does your pain have on your sleep? Would you be interested in

learning some skills that could make it easier for you to fall and stay asleep?

Education and Work History

How far did you get in school?

Are you currently not working because of pain?

When did you last work? What was your job?

[If not working] Is returning to work a realistic goal for you? How important is returning to work to you?

Are you currently receiving any fi nancial compensation due to disability because of the pain? [If so] How much per month, and from what sources?

Are there any litigation issues in this case? [If so] At what stage is the litigation?

Social Status and History Where were you raised?

By whom were you raised?

Description of childhood?

Were you ever abused physically, sexually, psychologically, emotionally? [If so] Can you tell me more about that?

Mark P. JensenHypnosis for Chronic Pain Management: Pain Evaluation Form. Copyright © 2011 by Oxford University Press

Oxford Clinical Psychology | Oxford University Press

How would you describe your mother? What kind of a parent was she?

How would you describe your father? What kind of a parent was he?

Are you married? [If so] How long have you been married? How would you describe

the quality of your relationship? What effects, if any, has the pain had on your relationship? [If not] Have you been married in the past? How many times? How did that/those relationship(s) end?

Do you have any children? [If so] How many? Do(es) he/she/they live with you?

What effects, if any, has the pain had on your relationship with your children?

Psychological/Psychiatric Status and History

Presence and history of depression:

Presence and history of post-traumatic stress disorder:

Presence and history of anxiety/panic disorder:

Presence and history of psychotic or delusional symptoms:

Treatment history for any current or past psychological or psychiatric problems:

Drug and Alcohol Use Status and History

How much do you usually drink each week?

Do you currently use other drugs?

Have you had problems with alcohol or drug use in the past? [If yes] Can you tell me

more about that?

Have you ever been treated for drug or alcohol abuse? [If yes] Can you tell me more

about that?

Mark P. JensenHypnosis for Chronic Pain Management: Pain Evaluation Form. Copyright © 2011 by Oxford University Press

Oxford Clinical Psychology | Oxford University Press