Qutenza Post-Treatment Scores (6-week feedback)

Please rate your pain by indicating the number that best describes your pain at its worst in the last week *

0 would be no pain and 10 would be pain as bad as you can imagine

Please rate your pain by ticking the number that best describes your pain AT ITS LEAST in the last week. *

0 would be no pain and 10 would be pain as bad as you can imagine

Please rate your pain by ticking the number that best describes your pain ON AVERAGE *

0 would be no pain and 10 would be pain as bad as you can imagine

Please rate your pain by ticking the number that tells how much pain you have RIGHT NOW *

0 would be no pain and 10 would be pain as bad as you can imagine

What has improved as a result of the Qutenza treatment? (Tick all those that apply to you) *

*Tick all those that apply to you*

No change
My sleep has improved
My pain has improved
My mood has improved
My fatigue has improved
I can do more physically
My family notice I am functioning better
I have been able to participate in more pleasurable activities/hobbies due to improvement
Fewer side effects because I have reduced requirement for painkillers

Your name *

Your date of birth *

*

Preparing for your visit with us: Before you arrive, during your stay and how we'll look after you