Bedfordview(GP) Bryanston(GP) Hillcrest(KZN) PMB(KZN) Umhlanga(KZN) Ballito(KZN) Constantia(WC) Paarl(WC) Kimberley(NC)
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Bedfordview Patient Forms – Defence and Veterns Pain Rating Scale

Home / Patient Forms / Bedfortview Patient Forms – Defence and Veterns Pain Rating Scale

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.

    DVPRS scale

    1. Select the one number that best describes your current level of pain:

    2. How has pain interfered with your usual ACTIVITY in the past 24 hours?

    0 = Does not interfere, 10 = Completely interferes

    3. How has pain interfered with your SLEEP in the past 24 hours?

    0 = Does not interfere, 10 = Completely interferes

    4. How has pain affected your MOOD in the past 24 hours?

    0 = Does not affect, 10 = Completely affects

    5. How much has pain contributed to your STRESS in the past 24 hours?

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

    Total DVPRS Score (out of 50):

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