Pain Control Evaluation Form

Replies to This Discussion

Permalink Reply by Rene Frederiksen on February 24, 2010 at 1:56pm

Hello Steve
Well - We do have different demands to that legal paper - Different setup towards the law areound the world - Even around the USA!
So I think you shall contact your org. and ask if they got something for your part of the world.
I have an Intake form - But thats more aimed towards the Danish market.....

Evaluation forms are easy -
We want to evaluate progress - So we need to know the intake of drugs - Pain levels during the day - Pain before the session
After the session and during the session.
We want to see the clint altering there pain preception -
AND if you record these info's - Be sure to have the law on the rigth side.
In Denmark you will need to reg. at the goverment and get approvle to keep such records.

You COULD build your own document - But check with the legal's in your org.
Have fun and help people :-)
Thats what its all about :-)

Best Regards
Rene Frederiksen
HypnoseForAlle.dk :-)

Permalink Reply by Anne Mullis on February 24, 2010 at 6:12pm

Steve - i've attached a copy of the form I use when I have a pain management patient in home care. I developed this on my own, so please feel free to use any or all of it. As you will note, I do not at any point, refer to using hypnosis in the questionaire - primarily due to Medicare regulations here in the US, which bascially keep me from using hypnosis without a specific order from their physician. And, since I am not licensed as a therapist, I am pretty much caught in a bit of a bind - so what I do discuss with my patients, is diet (within any pre-existing dietary restrictions, such as the patient being on warfarin, etc) and other distraction techniques. Anne
Pain Management Questionnaire

On a scale of 1 to 10, what is your pain level right this minute?
How long have you been experiencing the pain?


What are you doing at present to manage it? How well is it working for you?


Have you ever experienced any non-medication forms of pain management in the past? If so, what was it, and how well did it help in keeping your pain level down?


How well are you able to sleep, right now? How well were you able to sleep before experiencing the increase in pain?


What, if anything, do you do, to help yourself get to sleep at night?


Describe for me, the most relaxing place you’ve ever been or can imagine, anywhere in the world. What makes this place so relaxing for you?


On a scale of 1 to 10, what is your pain level now? (afterwards)