Spinal Cord Stimulator Evaluation

Spinal Cord Stimulator Evaluation

Please complete ONLY IF you are being seen for a one time psychiatric evaluation for Spinal Cord Stimulator.
Full Name*

PrefixFirst NameLast Name
Date of Birth*

MonthDayYear
Date of Birth
0-10 Numeric Pain Intensity Scale

Please complete the scale below for patients that are being evaluated for spinal cord stimulator pain clearance.

Please rate your average daily pain intensity on the scale:*

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Worst

During the past 7 days, how much have you been bothered by any of the following problems?- (SSS-8)*

	Not at all	A little bit	Somewhat	Quite a bit	Very much
Stomach or bowel problems
Back pain
Pain in your arms, legs or joints
Headaches
Chest Pain or shortness of breath
Dizziness
Feeling tired or having low energy
Trouble Sleeping

Should be Empty: