Pain Assessment Questionnaire — shared by the community
Clara D. shared this 13-question build with 1 conditional rule already wired up. Test it below, then take a copy.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 13 questions, 2 pages, 1 conditional rules.
- Shared by
- Clara D. · Non-profit programme lead
- Questions
- 13
- Replies
- 10
- Copies taken
- 103
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Live preview and test console
This is the real form. Answer it to test the 1 conditional rule — nothing is sent or stored.
Page 1 of 2 — Describe your pain
Every question on this page is currently visible.
Works for you? Take Clara D.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Pain Assessment Questionnaire is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 13 questions across 2 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 8 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It pins the request to a specific date.
- It allows multiple selections without free text.
- It captures a numeric value you can filter and sort on.
- Conditional logic hides 1 question until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Pain Assessment Questionnaire lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 1 conditional rule ship with it.
- Features advanced show logic: if “Does the pain interfere with daily activities?” is Yes, the form dynamically exposes “Describe how it interferes”. Otherwise that question never appears.
- All 1 rule are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
What this form asks
Page 1 — Describe your pain
- Patient full namerequired
- Date of birthrequired
- Date completedrequired
- Where is the pain located?required
- How would you describe the pain?
- How long have you had this pain?required
- Pain rating right now, from 0 (none) to 10 (worst possible)required
Page 2 — Pattern and impact
- What makes the pain worse?
- What makes the pain better?
- Does the pain interfere with daily activities?required
- Describe how it interferes
- Current medications taken for this pain
- Is the pain constant or does it come and go?required
Conditional logic in this build
- When “Does the pain interfere with daily activities?” is Yes, show “Describe how it interferes”.
Questions about this shared form
Does the rating scale diagnose anything?
No. It is a self-reported number the patient assigns; interpreting what it means for treatment is entirely up to the clinician reviewing it.
Should this be filled out at every visit?
For an ongoing condition, repeating it lets the clinician compare answers over time; a single completion works fine for a first assessment.
What if the patient has pain in more than one place?
The location field takes free text for exactly that reason; describe each area rather than picking the one that feels most urgent.
Can a caregiver complete this on the patient's behalf?
Only where the patient cannot answer for themselves, and note on the form who actually completed it and their relationship to the patient.
Is the Pain Assessment Questionnaire template free to use?
Yes. You can preview and test Pain Assessment Questionnaire on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Pain Assessment Questionnaire template ask for?
It asks 13 questions across 2 pages, 8 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Pain Assessment Questionnaire form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
1 conditional rule ships with the template: Features advanced show logic: if “Does the pain interfere with daily activities?” is Yes, the form dynamically exposes “Describe how it interferes”. Otherwise that question never appears. All 1 rule are editable in the Logic tab, and the built-in checker warns about rules that contradict each other. All rules are editable in the Logic tab.
Where do responses to the Pain Assessment Questionnaire form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Pain Assessment Questionnaire form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
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