Mai Device Pain Assessment - Pre-Assessment

*(Completed by the patient before receiving a device)*

Please use this Scale to answer the questions that ask for a (1 to 10) Pain rating:

*** (In rating Pain, consider 0 as "No Pain" and 10 as "Worst Pain Ever") ***

A. When did your pain begin?

B. What caused your pain to begin? (Ex: injury, accident, illness, no cause, etc.)

C. Has a doctor diagnosed you with a diagnosis/cause/illness? If so, please describe.

D. Where do you feel pain throughout your body?

E. Where do you feel pain the most on your body?

F. How often throughout the day do you feel pain? (Ex: constant, morning only, on-and-off, etc.)

G. How many days per week do you feel pain?

H. Using the Pain Scale above, how do you rate your pain usually (1 to 10)?

I. Using the Pain Scale above, how do you rate your pain when it is at its worst (1 to 10)?

J. What makes the pain feel better? (Ex: medicine, resting, icing, heating, stretching, etc.)

K. What makes the pain feel worse? (Ex: working, standing, walking, lifting, bending, etc.)

L. Describe your pain: (Ex: sharp, aching, tightness, numbness, burning, electric, etc.)

M. What medications, treatments or procedures have you tried to improve the pain?

N. Were any of them significantly successful? If yes, for how long? (please list them)

O. Does the pain affect your mood?

P. Using the Pain Scale, how bad is your Pain right now (1 to 10)?

Cancel