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  2. 2011
  3. October
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  5. Phantom Pain Characteristics
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Reason for Amputation
 
Traumatic
 
Non-traumatic, diabetees/vascular disease
 
Non-traumatic, cancer
 
Non-traumatic, other
 
 
 
Did you have pain in your limb prior to amputation?
 
Yes
 
No
 
 
 
If yes, was it for:
 
less than one week
 
1-4 weeks
 
1-6 months
 
half to one year
 
more than one year
 
Not applicable
 
 
 
If yes, please rate the intensity of the pre-amputation pain with 0=no pain and 10= So much pain I would faint
0 1 2 3 4 5 6 7 8 9 10
* Pain intensity
 
 
 
Was your limb paralyzed (i.e. caused by an actual nerve or brain injury) prior to amputation?
 
Yes
 
No
 
 
 
Was your limb immobilized or unable to bear weight prior to amputation?
 
Yes
 
No
 
 
 
Do you currently or have you ever had phantom limb sensation?
 
Yes
 
No
 
 
 
How soon following an amputation did you begin to experience phantom limb sensation?
 
I have never experienced phantom limb sensation
 
Immediately
 
Within a week
 
Within a month
 
Within three months
 
Within a year
 
After a year
 
 
 
If you have experienced phantom limb sensation, are you able to move your phantom at will?
 
Yes
 
No
 
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