Montreal: Improve Access to Specialist Care through eConsult for Patients Living with Chronic Pain default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. Thank you for participating in this study. The objective of this study is to evaluate the needs of patients who live with pain and their experience of the referral process from the perspective of patients like you. As a consumer of health care services, your experiences and views are highly valuable to this research. Your participation in the study involves completing a survey, which will ask about your experience in waiting to see the pain specialist and the referral process overall. The survey will take approximately 10 to 15 minutes to complete. You may skip any questions that make you uncomfortable or that you do not wish to answer. The survey doesn’t include your name or any other personal information that could be linked back to you. Your participation in this study is completely voluntary and will not affect the usual medical care you receive at this pain clinic This survey is anonymous. The record of your survey responses does not contain any identifying information about you, unless a specific survey question explicitly asked for it. If you used an identifying token to access this survey, please rest assured that this token will not be stored together with your responses. It is managed in a separate database and will only be updated to indicate whether you did (or did not) complete this survey. There is no way of matching identification tokens with survey responses. 1 What is/are the main reason(s) you are here to see the specialist? Check all that apply New pain (acute pain, less than 3 months) Chronic pain (more than 3 months) Cancer pain Post-operative pain Other (please specify) 2 How long have you been experiencing this pain? Choose one of the following answers Less than 3 months 3 months to 6 months 6 months to 1 year 1 year to 2 years 3 years to 5 years 6 years to 10 years More than 10 years 3 Who referred you to this pain clinic? Choose one of the following answers My usual family doctor My nurse practitioner A walk-in clinic doctor An emergency room doctor Another specialist doctor I don't know Other (please specify) 4 Do you have a regular health care provider? By this we mean one health professional that you regularly see or talk to when you need care or advice for your health? Choose one of the following answers Yes No 5 Is that regular health care provider a...? Choose one of the following answers Family doctor or general practitioner Medical specialist such as a cardiologist Nurse practitioner Other (please specify) 6 How long have you been waiting for this appointment since you were referred to this pain clinic? Choose one of the following answers Less than 3 months 3 months to 6 months 6 months to 1 year 1 year to 2 years 2 years or more 7 While waiting for your appointment at the pain clinic, has your pain... Not at all A little bit Moderately Quite a bit Extremely Caused you to miss work/school Not at all A little bit Moderately Quite a bit Extremely Caused you to worry more Not at all A little bit Moderately Quite a bit Extremely Limited your ability to carry out normal activities of daily living (e.g. preparing and eating meals, household tasks, sleeping, personal hygiene, etc.) Not at all A little bit Moderately Quite a bit Extremely Limited your ability to participate in your usual social or recreational activities Not at all A little bit Moderately Quite a bit Extremely 8 While waiting for this appointment, what other health care professionals/settings have you seen for your pain? 0 times 1-2 times 3-5 times More than 5 times Your family doctor/nurse practitioner 0 times 1-2 times 3-5 times More than 5 times Emergency Department 0 times 1-2 times 3-5 times More than 5 times Hospital stay (more than 1 day) 0 times 1-2 times 3-5 times More than 5 times Medical specialist 0 times 1-2 times 3-5 times More than 5 times Physiotherapist 0 times 1-2 times 3-5 times More than 5 times Occupational therapist 0 times 1-2 times 3-5 times More than 5 times Psychologist/pyschotherapist 0 times 1-2 times 3-5 times More than 5 times Chiropractor 0 times 1-2 times 3-5 times More than 5 times Pharmacist 0 times 1-2 times 3-5 times More than 5 times Community program (e.g., self management/educational support) 0 times 1-2 times 3-5 times More than 5 times Other (please specify) 0 times 1-2 times 3-5 times More than 5 times 9 Other health care professionals/settings you have seen for your pain: 10 Is there anything else you would like to tell us? 11 How did you arrive to the pain clinic today? Choose one of the following answers Regular bus Special transport (i.e. handicap bus) Someone came with me or dropped me off Walked Biked By personal car Taxi/drive sharing service Other (please specify) 12 Have you ever missed a health care appointment due to any of the following? Check all that apply. If none apply, please go to question 12. Check all that apply Didn't have a way to get to the appointment (no transportation) It was too far away It was too expensive to get there I had no one to take me that day My pain was too severe I had to care for another person I couldn't pay for the visit (e.g. no provincial insurance) My communication needs could not be met (e.g. interpreter) The office could not accommodate my physical needs (e.g. wheelchair, lifts) Forgot about the appointment I couldn't attend because of work or school/exams Other (please specify) 13 Do you have immediate support, such as family or friends, who help you with your health care appointments if needed? Choose one of the following answers Yes No Other (please comment) 14 In what year were you born? (Enter 4-digit birth year; for example, 1976) Only numbers may be entered in this field. 15 What is your gender? Choose one of the following answers Female Male Other Prefer not to answer 16 Please provide the first 3 digits of your postal code 17 Last week, was your main activity working at a paid job or business, looking for paid work, going to school, caring for children, household work, retired or something else? Choose one of the following answers Working a paid job or business Vacation (from paid work) Looking for paid work Going to school (including home schooling and vacation from school) Caring for children Household work Retired Maternity/paternity leave Long term illness Volunteering Care-giving other than for children Other (please specify) 18 Do you have insurance that covers all or part of the cost of your prescription medications? Choose one of the following answers Yes No 19 If yes, is it...? Choose one of the following answers A government-sponsored plan An employer-sponsored benefit plan A plan sponsored through an association such as a union, trade association or student organization Other, such as your own private plan purchased from an insurance company 20 Do you have insurance that covers all or part of your long-term care costs, inluding home care? Choose one of the following answers Yes No 21 If yes is it...? Choose one of the following answers A government-sponsored plan An employer-sponsored benefit plan A plan sponsored through an association such as a union, trade association or student organization Other, such as your own private plan purchased from an insurance company Submit Load unfinished survey Resume later Please confirm you want to clear your response? Exit and clear survey Toggle navigation Load unfinished survey Resume later ×