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Demographics/Medical History
Some secondary school – grade 7 to 11 Demographics/Medical History
PLEASE ENTER IDENTIFYING INFORMATION BEFORE PROCEEDING. Please answer all of the following questions regarding your most recent contact with Pain Questions
1. Have you had any pain prior to your last contact with the clinic? 2. During your last visit to this clinic, did any medical professional discuss pain that 3. Check the healthcare professionals with whom you had a conversation regarding ____ Other (specify :__________________________) Patient Self-Report Resource Utilization 5. Did the healthcare professional ask you how bad your pain was? 6. Did the healthcare professional discuss pain medication? 7. On scale from 1 to 5, do you agree with the following question: “I wish providers at this clinic could have done more to address the pain I Depression
1. Have you felt sad or depression prior to your last contact with the clinic? 2. During your last visit to this clinic, did any healthcare professional discuss sadness or depression that you may be experiencing? 3. Check the healthcare professionals you spoke to about depression. ____ Other (specify:__________________________) Patient Self-Report Resource Utilization 5. Did the healthcare professional ask you how bad your sadness or 6. Did the healthcare professional discuss medication to treat your sadness or depression such as antidepressant medication? 7. On scale from 1 to 5, do you agree with the following question: “I wish healthcare professionals at this clinic could have done more to address my feelings of sadness and depression.” 1. Have you felt fatigued or tired prior to your last contact with the clinic? 2. During your last visit to this clinic, did any healthcare professional discuss Patient Self-Report Resource Utilization 3. Check the healthcare professionals you spoke to about fatigue or ____ Other (specify:__________________________) 5. Did the healthcare professional ask you how bad your fatigue was ? 6. Did the healthcare professional discuss anemia (low blood) medication? 7. On scale from 1 to 5, do you agree with the following question: “I wish providers at this clinic could have done more to address my Patient Self-Report Resource Utilization PLEASE ENTER IDENTIFYING INFORMATION BEFORE PROCEEDING. MEDICAL EXPENSES QUESTIONNAIRE

Directions: Please use the past 3 months as the time frame for
answering these questions. Just do the best you can to estimate number of
visits, etc. The phrase “medical visits” refers to visits to any doctor, nurse,
hospital or pain management clinic to manage your pain, depression, or
fatigue.
1. How many pain-related medical visits did you have in the past 3 months?
2. How many depression-related medical visits did you have in the past 3
3. How many fatigue/anemia-related medical visits did you have in the past
4. Over the past 3 months, how many times did you go to the emergency room for pain?
5. Over the past 3 months, how many times did you go to the emergency room for depression?
6. Over the past 3 months, how many times did you go to the emergency Patient Self-Report Resource Utilization room for fatigue/anemia?
7. Were you admitted to the hospital because of your pain? (Please check
If you answered “Yes,” how many times were you admitted? 8. 5. Were you admitted to the hospital because of your depression?
If you answered “Yes,” how many times were you admitted? 9. Were you admitted to the hospital because of your fatigue/anemia?
If you answered “Yes,” how many times were you admitted? Patient Self-Report Resource Utilization
Prescription Medication Visits
10. In the last 3 months, have you taken any drugs that are commonly used to treat depression, Such as… (Please circle all that apply)
a) Anafranil [Clomipramine (hydrochloride)]? b) Aventyl or Pamelor [Nortriptyline hydrochloride)]? c) Effexor [Venlafaxine (hydrochloride)]? d) Elavil or Endep [Amitriptyline (hydrochloride)]? g) Morpramin [Desipramine (hydrochloride)]? m) Tofranil [Imipramine (hydrochloride)]? n) Wellbutrin [Bupropion (hydrochloride)]? Specify: ______________________________________ Patient Self-Report Resource Utilization 11. In the last 3 months, have you taken any of the following drugs that are commonly used to control pain…(Please circle all that apply)
b) Darvocet [Propoxyphena/Acetaminophen]? d) Demerol [meperidine (hydrochloride)]? e) Dilaudid [Hydromorphone (hydrochloride)]? g) Elavil or Endep [Amitriptyline (hydrochloride)]? o) Roxicodone [Oxycodone (hydrochloride)] q) Tophranil [Imipramine (hydrochloride)]? r) Tylenol #3 or #4 [Acetaminophen/Codeine]? s) Vicodin, Vicodin ES, or Vicodin HP [hydrocodone/Acetaminophen]? Specify: ________________________________________ 12. In the last 3 months, have you taken any of the following drugs that are commonly used to treat anemia?
Darbepoietin Alpha (Aranesp)? _____ No _____ Yes Procrit (Erythropoetin)

Source: http://www.hetinitiative.org/grantee_instruments/Medstat%20Draft%20Survey.pdf