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.

This information will be collected for educational purposes, however it will remain anonymous.