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Questionnaire Part Three

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These are some questions on your current treatment.

Section 1

Are you taking any of the following:

1.    paracetamol/acetaminophen; aspirin
2.    anti-inflammatories
3.    morphine-related medication including codeine, cocodamol, morphine, tramadol etc.
4.    antidepressants such as amitriptyline, fluoxetine etc. (please indicate dose) FOR PAIN
5.    anticonvulsants such as gabapentin, pregabalin (Lyrica) , lamotrigine etc.
6.    muscle relaxants such as diazepam, clonazepam, baclofen
7.    treatment for bladder problems
8.    other including treatment of constipation, sleeping tablets (please list all) related to arachoiditis problems
9.    antidepressants for depression/anxiety
10.    other : for unrelated conditions e.g. hypertension

Section 2

Other treatments:

1.    herbal/homoeopathic
2.    vitamins/supplements including cod liver oil etc.
3.    acupuncture
4.    TENS
5.    Physiotherapy
6.    Hydrotherapy
7.    Epidural steroid injection/ facet joint injection  (please indicate number)
8.    surgery
9.    intraspinal pump
10.    spinal cord stimulator

For each, please indicate how long you have been having this treatment and whether it is effective in (a) reducing pain and (b) improving function (allowing you to do more).

Section 3

Side effects:

Please indicate if you have any of the following side effects and which medication you think is causing the problem:

1.    constipation
2.    nausea
3.    dry mouth
4.    indigestion/ ulcers
5.    skin rash
6.    sleepiness/fatigue
7.    poor concentration/memory
8.    loss of balance/falls
9.    tremor
10.    addiction
11.    Other (please specify)

Do you need to take additional medicines to counter these side effects?

Have you had any allergic reaction to medication?

Many thanks for your time, and all these answers are of course confidential.

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