Date: / / Study Name: (month) (day) (year) Protocol ...
Copyright 1991 Charles S. Cleeland, PhD Pain Research Group All rights reserved PLEASE USE BLACK INK PEN Subject's Initials : _____ PI: _____
Download Date: / / Study Name: (month) (day) (year) Protocol ...
Information
Domain:
Source:
Link to this page:
Documents from same domain
n i a p e l nb i i as pso oN p1234567890t s r o0W1
npcrc.orgCapital Health Guidelines for using the Edmonton Symptom Assessment System (ESAS) CH-0373 Mar 2001 Regional Palliative Care Program Purpose of the ESAS This tool is designed to assist in the assessment of …
The Brief Pain Inventory - NPCRC
npcrc.org25) I take my pain medicine (in a 24 hour period): 1. Not every day 4. 5 to 6 times per day 2. 1 to 2 times per day 5. More than 6 times per day
Brief Fatigue Inventory - NPCRC
npcrc.orgDate: / / Time:_____ Name:_____ _____ _____ Last First Middle Initial Brief Fatigue Inventory
HAMILTON DEPRESSION RATING SCALE - NPCRC
npcrc.orgThe total Hamilton Depression (HAM-D) Rating Scale provides and indication of depression and, over time, provides a valuable guide to progress. • Classification of symptoms which may be difficult to obtain can be scored as:
Caregiver Strain Index (CSI) - NPCRC
npcrc.orgCaregiver Strain Index (CSI) I am going to read a list of things that other people have found to be difficult. Would you tell me whether any of these apply to you?
McGILL QUALITY OF LIFE QUESTIONNAIRE - NPCRC
npcrc.orgMcGILL QUALITY OF LIFE QUESTIONNAIRE STUDY IDENTIFICATION #: DATE: Instructions The questions in this questionnaire begin with a statement followed by two opposite answers. Numbers extend from one extreme answer to its opposite. Please circle the number between 0 and 10 which is most true for you. There are no right or wrong answers.
Geriatric Depression Scale (GDS) Short Form - NPCRC
npcrc.orgScoring for Geriatric Depression Scale • Score 1 point for every “yes” in questions 2, 3, 4, 6, 8, 9, 10, 12, 14, 15 • Score 1 point for every “no” in ...
Related documents
MODIFIED OSWESTRY LOW BACK PAIN …
longvieworthopedic.comMODIFIED OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE Section 2 (con’t): To be completed by patient Standing _____I can stand as long as I want without increased pain.
The Roland – Morris Low Back Pain and Disability …
www.anatomyfacts.comThe Roland – Morris Low Back Pain and Disability Questionnaire Patient name: _____ File # _____ Date: _____ Please read instructions: when your back hurts, you may find it difficult to do some of the things you
Oswestry Back Disability Index
www.brain-spine.comFRONT RANGE CENTER for BRAIN & SPINE SURGE. RY, P.C. 1313 Riverside Ave., Ft. Collins, CO 80524 (970) 493-1292. Oswestry Back Disability Index. This questionnaire is designed to help us better understand how your back pain affects your ability
The Roland-Morris Low Back Pain and Disability ...
www.srisd.comThe Roland-Morris Low Back Pain and Disability Questionnaire Patient name: File # Date:
NEW PATIENT HEALTH HISTORY AND PAIN …
www.valleypain.orgPage 3 of 5. TREATMENT HISTORY: If you have tried any of the listed treatments, please indicate whether it helped with your pain or not by checking the appropriate box.
Related search queries
MODIFIED OSWESTRY LOW BACK PAIN, MODIFIED OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE, Pain, Back Pain and Disability, Back Pain and Disability Questionnaire, Oswestry Back Disability Index, Questionnaire, Disability, Back Pain and Disability Questionnaire Patient name: File, NEW PATIENT HEALTH HISTORY AND PAIN