Thank you for getting in touch with us. We continue to use PIFU (Patient Initiated Follow Ups) to support patients to contact the service when they are ready for their next appointment.

Would you kindly fill out the details below so that we can direct your request appropriately, thank you very much for taking the time to do so.

• Your name Please enter your name
• Your date of birth
• Preferred contact telephone number
• Preferred email address
• 1. Why have you got in touch with the Dorset Pain Management Service today?
• 2. Is there anything that you would like to ask members of our Pain team?
• 3. When was your most recent procedure within our Service? (approximate dates)
• 4. On a scale of 0-9 how much relief did you receive for your pain following this intervention or procedure? (if applicable)
  0= no relief and 9= complete relief from pain
  0
  1
  2
  3
  4
  5
  6
  7
  8
  9
  
• 5. How long did this level of pain relief last for?

  Less than 1 month

  1 - 3 months

  3 - 6 months

  6 - 9 months

  9 - 12 months

  Longer: please specify

• 6. After your last intervention, did your pain medication use change?
  I'm using more I'm using the same I'm using less
• 7. After your last intervention did your sleep quality change?
  My sleep was worse I’m sleeping the same My sleep was better
• 8. After your last intervention did your mood change?
  My mood got worse My mood stayed the same My mood improved
• 9. After your last intervention did your ability to carry out daily activities change?
  I did less activity I did the same level of activity I did more activity
• 10. Has your pain condition affected any of the following since you were last seen by our team? None Motor weakness e.g. muscle weakness or co-ordination Sensory loss e.g. numbness or tingling Change in bladder or bowel function e.g. accidents or unable to go Other
• 11. Are you taking any blood thinners/anticoagulants? (please give details)
• 12. Have you been newly diagnosed with any of the following medical conditions since your last medical procedure with the pain service? Heart problem Breathing problem Neurological problem Diabetes Other
• 13. Please feel free to include any other information you feel might be relevant for us to know

• Thank you for your information.

  Once we receive this from you, our clinicians will discuss your request at our next Multidisciplinary meeting.

  We will then contact you to confirm the next steps.

• Consent is required I give my consent for a member of the team at Dorset Pain Management Service to contact me by email and/or telephone.
• GDPR acknowledgement is required I acknowledge the Data Protection (GDPR) and Confidentiality information
• Send