Neuropathic Pain Diagnostic Questionnaire

Please complete this questionnaire by checking one answer for each item in the four questions below.

  INTERVIEW OF THE PATIENT
  Question 1: Does the pain have one or more of the following characteristics?  
 
  YES NO
 1 - Burning
 2 - Painful cold
 3 - Electric shocks
 
  Question 2: Is the pain associated with one or more of the following symptoms in the same area?  
 
  YES NO
 4 - Tingling
 5 - Pins and Needles
 6 - Numbness
 7 - Itching
 
     

  EXAMINATION OF THE PATIENT
  Question 3: Is the pain located in an area where the physical examination may reveal one or more of the following characteristics?  
 
  YES NO
 8 - Touch Hypoaesthesia
 9 - Pricking Hypoaesthesia
 
  Question 4: In the painful area, can the pain be caused or increased by?  
 
  YES NO
 10 - Brushing ( for example: using a Von Frey hair brush )
 
     

   



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D. Bouhassira et al. Pain. 2005 Mar 114(1-2): 29-36.

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  Results
 

Your score was 0/10

You are unlikely to have neuropathic pain. However, if you are concerned, or pain persists, go see your doctor.

You answered:

Use the following questions to help assess your pain.
On the diagram below, please indicate the areas where the patient feels pain.
 
How did the pain develop?
 
Pain pattern: are there specific times of the day or night when the pain is most intense?
 
What level of interference does the pain present?
  0 1 2 3 4 5 6 7 8 9 10
General activity
Mood
Normal work
Relationship
Sleep
Enjoyment of life
  0 = Does not interfere10 = Completely interferes
 
What kind of things help ease the pain?
 
What medication or treatment is the patient currently receiving?
 
How much relief has this treatment provided?
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
0% = No relief100% = Complete relief