Interviewer:
Demographics
Patient number: Age: Gender: Weight: kg EGFR:
Operation:
Days post-op:
Pain score (0-10): in recovery________
Intra-op of Spinal Diamorphine mg Dose of Spinal Bupivicaine mg
Intra-op morphine:
PCA use in first 24hours postop:- Morphine mgs
Fentanyl mgs
Other
Postop
Analgesia
IV lidocaine Ketamine Paracetamol NSAIDs Other
Y or N

Pain – rate your current pain at rest on a scale between 0=minimal pain and
4=maximal imaginable pain

Vomiting – please grade any distress and bother from vomiting since the surgery
(0=not at all to 4 = very much)

Itching
– please grade any distress and bother from itching since the surgery (0=not at all to 4=very much)

Sweating – please grade any distress and bother from sweating since the surgery
(0=not at all to 4=very much)

Freezing – please grade any distress and bother from freezing since the surgery
(0=not at all to 4= very much)

Dizziness
– please grade any distress and bother from dizziness since the surgery
(0=not at all to 4 = very much)

Satisfaction with pain – how satisfied are you with your pain treatment since the surgery (0=not at all to 4= very much)

Are you managing to eat a light diet? Y N

Have you passed wind down below or though your stoma since surgery? Time?
Y N