Phantom Limb Pain Questionnaire Form
Please answer the following questions to help us better understand your experience with phantom limb pain.
Full Name
*
First Name
Last Name
Age
*
Location of Amputation
*
Please Select
Arm
Leg
Hand
Foot
Other
Year of Amputation
How often do you experience phantom limb pain?
*
Daily
Several times a week
Once a week
Less than once a week
Never
Please rate the average intensity of your phantom limb pain.
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst imaginable pain
10
0 is No pain, 10 is Worst imaginable pain
How would you describe the quality of your phantom limb pain? (Select all that apply)
Burning
Stabbing
Aching
Tingling
Cramping
Other
When did you last experience phantom limb pain?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you tried any treatments or medications for phantom limb pain?
Yes
No
Please describe how phantom limb pain affects your daily life.
Submit
Should be Empty: