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7. Chronic pain means that an injury hasn't healed properly. 8 The body tells the brain when it is in pain. 9. Nerves adapt by making ion channels stay open. BACK PAIN QUESTIONNAIRE. Page 2 of 3. Patient Name: Ref ID: This questionnaire has been designed to give the doctor information about how your neck pain hasIt can be used to monitor the pain over time and to determine the effectiveness of any intervention. It was developed at by Dr. Melzack at McGill University in Page 1. PAIN QUESTIONNAIRE. Date: ______ Patient: Last name: First name: '. How would you assess your pain now, at this moment? This questionnaire will help assess the two parts of chronic pain that often change over time, persistent baseline and breakthrough pain. Please take a moment. Once your physician receives this package, a referral will then be forwarded to the UHNBC Pain Clinic. Date: Address: Phone #:. Primary care physician:. Objectives : The Dallas Pain Questionnaire (DPQ), which is a 16-item visual analog tool was developed by Lawlis, McCoy, and Selby (appendix) for the purpose PAIN QUESTIONNAIRE. Name: Date of Birth: Today's date. The following pages contain information that will help us to best understand your pain and how it Örebro Musculoskeletal Pain Screening Questionnaire (Short). Name: Date of Birth: Are you: Male. Female. 1. How long have you had your current pain problem?