Bedfordview Patient Form – Defence and Veterans Pain Rating Scale

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This form is strictly confidential and is encrypted with a SSL certificate on a secure server. We never share your information with any third parties. Alternatively you can download a copy of the form and submit it to bedfordadmin@ketamind.co.za.

A copy of your results will be emailed to KetaMIND Clinics South Africa. Should your score indicate you are severely in pain, we may contact you to discuss available treatment options, including but not limited to KCSA Infusion Therapy.

This form is to be filled in prior to coming in for treatment.

    PRS Supplemental Questions

    For clinicians to evaluate the biopsychosocial impact of pain.

    1. Select the one number that best describes your current level of pain based on the above graphic:











    2. Select the one number that describes how, during the past 24 hours, pain has interfered with your usual ACTIVITY:

    0 - Does not interfere, 10 - Completely interferes











    3. Select the one number that describes how, during the past 24 hours, pain has interfered with your SLEEP:

    0 - Does not interfere, 10 - Completely interferes











    4. Select the one number that describes how, during the past 24 hours, pain has affected your MOOD:

    0 - Does not affect, 10 - Completely affects











    5. Select the one number that describes how, during the past 24 hours, pain has contributed to your STRESS:

    0 - Does not contribute, 10 - Contributes a great deal











    Total score out of 50

    No single test is completely accurate. You should always consult your physician when making decisions about your health.