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Chronic Pain Management MR#: Pain Assessment Questionnaire

Chronic Pain Management MR#: Pain Assessment Questionnaire 2025

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The document is a Back Pain Questionnaire designed for individuals applying for life insurance with The Wawanesa Life Insurance Company. It collects detailed information about the applicant's history of back or neck pain, including frequency, duration, treatment received, and any related medical investigations or surgeries. The questionnaire also requires a declaration of truthfulness regarding the provided information.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (68 Votes)
2018	4.4 Satisfied (61 Votes)

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What are the 7 components of pain assessment?

Pain has seven dimensions, or core aspects: physical, sensory, behavioral, sociocultural, cognitive, affective, and spiritual. To perform a comprehensive pain assessment, you must understand what each dimension encompasses and be able to evaluate all dimensions accurately.

What are the 5 As of chronic pain management?

Regular assessment with the 5 As (i.e., analgesia, activity, adverse effects, aberrant behaviors, and affect) Periodically review pain diagnosis and comorbid conditions, including substance use disorders.

What questions are asked during a pain management assessment?

Page 1 Pain history. Where do you have pain/are you sore/ aching or hurting? General medical history. What medical conditions have you been diagnosed with? Review of medications and other. treatments. What medications are you currently taking? Physical impact of pain. How does it feel when you move?

What is the MPQ pain questionnaire?

The McGill Pain Questionnaire consists primarily of 3 major classes of word descriptors--sensory, affective and evaluative--that are used by patients to specify subjective pain experience. It also contains an intensity scale and other items to determine the properties of pain experience.

What are the 5 As of pain assessment?

Questions we ask about your pain How long have you been in pain? Was there an inciting injury, or how did it develop? Where is the pain located. How intense is the pain how would you describe it? When do you feel the pain most? Is the pain taking a toll on your quality of life?