SOCRATES Pain Assessment

Full Name *

Date of birth *

Telephone/Mobile Number *

Email Address

Site : Where exactly is the pain? *

Onset : When did the pain start, was it constant/intermittant, gradual/sudden? *

Character : What does the pain feel like e.g. sharp, burning, tight? *

Radiation : Does the pain radiate/move anywhere? *

Associations : Is there anything else associated with the pain e.g. sweating, vomiting? *

Time Course : Does the pain follow any time pattern, how long did it last? *

Exacerbating/Relieving Factors : Does anything make it better or worse? *

How severe is the pain on the following scale? (1 little pain / 10 extreme pain) *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

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