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Medicaid: Forms An Analyst May Ask You To Complete (Supplemental Questionnaires)

How To Complete The Pain Questionnaire

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Pain, like fatigue, is a subjective symptom that cannot be measured in the lab and is not generally observable by a medical practitioner. So Medicaid has a special questionnaire to try to put some measurement to the severity of your pain. 

The Pain Questionnaire asks very specific questions about your pain such as the following:

  • Where is it located?
  • Is the pain a throb, an ache, sharp or stabbing?
  • How frequent is the pain?
  • Does the pain spread or move?
  • Does lying down or resting or medication relieve the pain? If so, how successfully and for how long?
  • How does the pain impact your activities and your ability to concentrate and think clearly?
  • Do you wear or use any device to relieve the pain or its effects?  Be specific. Describe everything you do to relieve pain, whether it's cool baths, warm baths, staying in a dark room, listening to music, loose clothing, sunglasses to cut down on glare or whatever.
  • Even if it's in the medical records, mention any treatment you've tried for pain such as acupuncture, chiropractic treatment, massage or meditation.

Be very specific in your answers. Describe how pain has affected your daily routine. For example, if you can no longer take walks or participate in sports because of pain, mention it.  

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