疼痛调查问卷模板

11访问日期：口年月口口日(圈出适当者）□62□7□8□9□10□11□12[如连以上的症状都没有→sectionH,p.19]*或［圈出适当者］膀?［圈出适当者］3□13［填入編號］□14［填入編號］□15［圈出适当者］有/无［圈出适当者］4.严重的痛B部分：病历 2.最近八至三十日内6.超3.超过三十日至三个月内7.超过两年至四年内 4［填入編號］□16［填入編號］□16［填入編號］□17［填入編號］□18 2.最近八至三十日内6.超3.超过三十日至三个月内7.超过两年至四年内 2.八至三十日内7.超过两年至四年内 C部份：颈痛的严重程度5［填入編號］□19［填入編號］□［填入編號］□19［填入編號］□20［填入編號］□214.使你每晚的睡眠时间少过五小时4.使你每晚的睡眠时间少过五小时5.使你每晚的睡眠时间少过两6［填入編號］□22［填入編號］□23［填入編號］□22［填入編號］□23［填入編號］□244.你只可以拿起轻的物件4.颈痛逼使你提早停止这些活动7［填入編號］□25［填入編號］□26［填入編號］□25［填入編號］□26［填入編號］□274.只能局限于家裹4.经常限制你驾驶8□28［填入編號］□29□30□31□32□33□34□35□36□37□38□39□40有/无sectionE,p.11［读出下列各项］其他(注明)其他(不读出)［可圈一项或多项］有/无有/无有/无有/无有/无有/无有/无有/无有/无有/无有/无9□41□42□43□44□45□46□47□48□49□50□51□52E部份：医疗服务和支出［读出下列各项］［圈出适当者］有/无有/无有/无□53□54□57□60□63□66□69□72□75□78□81□84□87□90□93□□55-56□□58-59□□61-62□□64-65□□67-68□□70-71□□73-74□□76-77□□79-80□□82-83□□85-86□□88-89□□91-92□□94-95［圈出适当者］有/无［圈出适当者］□96□□97-98□99□□100-101□96□□97-98□99□□100-101□102［填入編號］［填入5b題編號］□103□□104-105［填入編號］□106无/有无/有 ［圈出适当者］有有/無［圈出适当者］有/无□107［填入次數］□□108-109［填入編號］□□107［填入次數］□□108-109［填入編號］□110［填入數字］□□111-112［填入編號］□113 次［圈出适当者］ 晚 4.超过三个月至六个月内［圈出适当者］□114［填入數字］□115□114［填入數字］□115［填入編號］□116［填入編號］□117 次 4.超过三个月至六个月内［圈出适当者］［填入編號］□117a［填入編號］□□［填入編號］□117a［填入編號］□□118-119□120［圈出适当者］□121［填入編號］□121［填入編號］□122□123［填入日數］［圈出适当者］编号［圈出适当者］活动等)?［圈出适当者］有/无□□□124-126□□□124-126□127［填入日數］□□□128-130□131［圈出适当者］有/无 日以下问题是问关于你的工作的,［圈出适当者］□□132-133［填入編號］□134□□132-133［填入編號］□134□135□□136-137［填入編號］□138［填入小時］全職□□139-140编号［圈出适当者］4.超过三个月至六个月内［圈出适当者］有/无编号［圈出适当者］兼職□□141-142全職+兼職□□兼職□□141-142全職+兼職□□143-144［填入編號］□145［填入編號］□146□147［填入編號］［圈出适当者］［圈出适当者］［圈出适当者］有/无编号［圈出适当者］□148［填入編號］□148［填入編號］□□149-1504.超过三个月至六个月内编号[不读出]［圈出适当者］20［填入編號］□151［填入年齢］□□［填入編號］□151［填入年齢］□□152-153编号［圈出适当者］6.其他[请注明]［填入年齢］岁21［填入編號］□154［填入編號］□［填入編號］□154［填入編號］□155［填入年數］□□156-157［填入編號］□158编号(不读出)［圈出适当者］［填入年数］年编号［圈出适当者］ 22编号［圈出适当者］调查员留意分访问需用时间:［填入編號］［填入編號］□1592312QuestionnaireforTelephoneSurveyonNeckPainDateofSurvey：yearmonth(Pleasecircletheappropriateone）□622e)severe2e)severe2a)Haveyoueverhadthefollowingsituationssince(Readoutthefollowingonebyone,circletheappropriateone)［Iftheclientcannotunderstandtheterms,youcanreadouttheexplanationsquoted］2.Anesthesia(Nosensation)4.Stiffness(Decreasesmoothnessofmovement)yes*Ifyouhadanyoneoftheabove,youhadsufferedfromneckpain![Ifnoneoftheabovesymptomswaschosen→sectionH,2b)Ifyouhavepaininotherbodyparts,doyouthinkneckpainisyourmain[Iftheclientcannotunderstandtheterms,youcanreadouttheexplanations*]thinkneckpainismoresevereincomparisonwitht［Circletheappropriateone］pointthatatthebackofyourhead)andshoul［Iftheclientcannotunderstandtheterms,youcanreadouttheexplanationquotedinthebracket］［Circletheappropriateone］yes/no→sectionH,2d)Doesyourneckpainextendtoupperarms,h［Circletheappropriateone］□7□8□9□10□11No=1□12□133［Fillinthecode］□［Fillinthecode］□144［Fillinthe［Fillinthecode］□15［Fillinthecode］□16［Fillinthecode］□17［Fillinthecode］□183a)Whendidyourfirstepisodeofneckpai years/months/days＊[4.3monthsago,butwi7.2yearsago,butwithi3b)Howmanyepisodesofneckpaindidyousufferduringlasttw episode(s)[Iftheclientcannotanswer,youcanreadoutthefollowingchoices]3c)Whendidyourrecentepisodeofneckpain(ortheprese 4.3monthsago,butwi7.2yearsago,butwithi3d)Howlongdidyourrecentepisodeofneckpain(ort 2.Between8to30da5［Fillin［Fillinthecode］□19［Fillinthecode］□20［Fillinthecode］□21［Fillinthecode］□22SectionC:Disabilityduetoneckpain3e)Howseveredidyoufeela1.Nopain3f)Thefollowingareabouttheimpactofyou［Readoutthefollowingitems,circlethemostappropriateoneonly］4.Becauseifpainyousleeplessthan5hourssleepintot5.Becauseofpainyousleeplessthen2hourssleepintotal3g)Howlongdidthepins［Readoutthefollowingitems,circlethemostappropriateoneonly］2.Youhaveoccasion3.Yoursleepisregularlydistu4.Becauseofpinsandneedlesyouhavelessthan5hourssleepintotal5.Becauseofpinsandneedlesyouhavelessthan2hourssleepintotal3h)Howlongdidyou［Readoutthefollowingitems,circlethemostappropriateoneonly］3.Symptomsarepresentonandoffforatotalperiodof1-4hoursperday4.Symptomsarepresentonandoffforatotalofmorethan4hoursperday5.Symptomsarepresentcont［Readoutthefollowingitems,circlethemostappropriateoneonly］6ofyourrecentneckpain(orthepresentone)oofyourrecentneckpain(orthepresentone)o2.Youcancarryheavyobjects,3.Painpreventsyoufromcarryingheavyobjects,bu4.Youcanliftlightweightobjects［Readoutthefollowingitems,circlethemostappropriateoneonly］2.Youcandothisa4.Paincausesyoutostopdoingthissoonertha5.Painpreventsmefworkingandhousework［Readoutthefollowingitems,circlethemostappropriateoneonly］2.Paindisturbsyoutodoyourusualworkandshorten<25%ofyourusualworkinghours3.Paindisturbsyoutodoyourusualworkandshortenbetween25%and50%ofyourusualworkinghours4.Paindisturbsyoutodoyourusualworkandshorten>50%ofyourusualworkinghours5.Painpreventsyoufrsocialactivities(eg.［Readoutthefollowingitems,circlethemostappropriateoneonly］2.Yoursociallifeisnormal,butincreasesthedegreeo3.Painhasrestrictedyoursociallife,bu4.Painhasrestrictedyoursociallifetothe5.Youhavenosociallifebecause3m)(Omitthisquestionifth［Fillinthecodes］□23［Fillinthecode］□24［Fillinthecode］□25［Fillinthecode］□267［Fillinthecode］□27No=1□28［Fillinthecode］［Fillinthecode］□27No=1□28［Fillinthecode］□29□30□31□32□33□34□35□36□37□38□39□403.Neckpainlimitsyourdrivingoccasiona4.NeckpainlimitsyourdrivingfrequentlySectionD:MedicalDiagnosis4a)Haveyoureversoughtanymedicalconsultationfor4b)Whichmedicalprofessiondidyouseekthecons4c)DidthemedicalprofessionmakeanydiagnosDidtheysayyouhadthefollowingsituatio［Readoutthefollowingitems］Bonepain/neckpain/cervicalspinedisProtrudedintervertebalPresenceofosteophytesOthers(donotreadout)8SectionE:MedicalServicesandRelatedExpenses5a)Haveyoutriedthefollowingmethodsindeal［Readoutthefollowing］2.Domassagewithointment/creamb(eg.Chineseherbcream,deephe4.Doonyourown:(Readoutthefollowing)b□41□42□43□44□45□46□47□48□49□50□51□52No=1□53yesyes/no/no/no/no/no/no/no/no/no/no/no/no5b)Haveyoubeentreatedbyotherpeople［Circletheappropriateone］9No=0Yes=1［FillintheNo=0Yes=1［Fillinthetimes］□54□57□60□63□66□69□72□75□78□81□84□87□90□93□96□□55-56□□58-59□□61-62□□64-65□□67-68□□70-71□□73-74□□76-77□□79-80□□82-83□□85-86□□88-89□□91-92□□94-95□□97-98□99□□100-101□102［FillinthecodeFillinthecodefrom□103□□104-105［Iftheclientcannotanswer,youcanreadoutthefollowingchoices］Now,Ireadoutthefollowingprofession,youjustneedtoansweryesorno［Circletheappropriateone］a.Generalpracticenb.Orthopedicsno/yesc.Otherspecialties2.Privatedoctors,howmanytimesda.Generalpracticeno/yes____b.Orthopedicsno/yes___c.Otherspecialtiesno/yes3.Physiotherapy(Howmanytimes?)no/yes4.Bonesetter(Howmanytimes?)no/yes6.Acupuncture(Howmanytimes?)no/y7.Herbmedicine,excludedbonesetter(Howmanyti8.Chiropractics(Howmanytimes?)no9.Solereflextherapy(Howmanytimes?10.Others[pleasespecify]12.AccidentandEmergencyservice5c)Wasthereanyimprovemen［Circletheappropriateone］Question5f5d)Whatwasthemosteffectivetreatmentamongthoseyou2.Allwereno——→5e)Ifyouthoughtthetreatmentwaseffective,howwastheeffect?［Fillinthecode］□106［Fillinthecode］□106□107［Fillinthecode］□□108-109［Fillin□thecode］［Fillinthenumberofnights］□□111-112［Fillin□thecode］No=1□1143.Improvedbymoret5f)iHaveyoustayedatthehospitalsforthereas［Circletheappropriateone］ iiiHowwastheeffectofstayingathospitaltoyourne［Circletheappropriateone］2.Improvedby4.Improvedbymorethan55g)iHowmanynights________night(s) 4.3monthsago,butwi7.2yearsago,butwithi5h)iHaveyoureceivedanysurgery［Circletheappropriate］［Fillin□thenumberofsurgery［Fillin□thenumberofsurgerydone］［Fillin□thecode］［Fillin□thecode］［Fillin□117athecode］ 4.3monthsago,butwi7.2yearsago,butwithinivHowwastheeffectofsur［Circletheappropriateone］2.Improvedbyless4.Improvedbymorethan5i)WhatwasthetotalexpensethatyIftheclientcannotanswer,lethimchoosefromthefo［Fillinthecode［Fillinthecode］□□118-119□121［Fillin□thecode］6a)Whatdoyouthinkaboutthemaincauseofyourneckpownfirst,iftheycannotanswer,readoutthefollowing］6b)Didthedoctorsaythatyourneckpainwas［Circletheappropriateone］6c)Ifyes,wasyourneckpainrelatedwiththefull-timeorpart-timej［Circletheappropriateone］6d)HowclosewastherelationbetweenneckpainandyourjoCodes［Circletheappropriateone］□123［Fillinthedays］□□□□127［Fillinthedays］□□□SectionG:EffectonDailyLife7a)Didyouchangethehabitofyourdailylife(eg.woreasonofneckpainduringthelasttwelv［Circletheappropriateone］7b)Howmanydaysdidyoucha7c)Didyoutakeanyleavesforthereasonofneckpainduring［Circletheappropriateone］7d)Howmanydaysofleavedidff□131［Classifythe□131［Classifytheoccufillinthecode］□□132-133［Fillin□thecode］□135［Classifytheoccufillinthecode］□□136-137［Fillin□thecode］Thefollowingquestionsareabou8a)Didyougotoworkdurin［Circletheappropriateone］8c)Howlonghadyouworkedwiththisjob/howlonghadyCodes［Circletheappropriateone］4.3monthsago,but7.2yearsago,butwithin［Circletheappropriateone］8e)Whatisyouroccupationin8f)Howlonghadyouworkedwiththispart-timCodes［Circletheappropriateone］3.30daysago,butwith4.3monthsago,butw［Fillintheworkinghours］Full［Fillintheworkinghours］Full-time□□139-140Part-time□□141-142□□143-144［Fillin□thecode］［Fillin□thecode］No=1□147［Fillin□thecode］2.Part-time:8h)Didyourfull-timejobrequi［Circletheappropriateone］2.Mildmanualwork(eg3.Moderatemanualwork(eg.t4.Intensivemanualwork(eg.constructionsiteworker)8i)Didyourpart-timejobreq［Circletheappropriateone］2Mildmanual3Moderatemanualwork(eg.technic4.Intensivemanualwork(eg.constructionsiteworker)8j)Haveyouchangedyourjobforthereasonofneckpain?［Circletheappropriateone］8k)WhendidyouchangeyourCodes［Circletheappropriateone］3.30daysago,butwith4.3monthsago［Fillinthecode］［Fillinthecode］□□149-150［Fillin□thecode］[pleasespecify]9a)WhichdistrictdoyoulCodes[Donotreadout]［Circletheappropriateone］9b)WhatkindofhousingdoyouCodes［Circletheappropriateone］2.HousingundertheH3.Privatehousing(wholefloor/wh5.Apartmentprovided［Fillintheage［Fillintheage］□□152-153［Fillin□thecode］［Fillin□thecode］fyears］□□156-157［Fillinthecode］□158［Fillintheage］［Iftheclientsdonotwanttoanswertheexactage,aCodes［Circletheappropriateone］