PAIN DIARY
STEP 2

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​REGISTER YOUR PATIENT PROFILE



Only complete this form once you have completed STEP 1 and received your UNIQUE PATIENT ID number

You only need to complete this form once​​. Once this form has been completed, you may use the 'Daily Pain Diary'​​


By using this Pain Diary, you undertsand that this does NOT form part of any medical treatment you may be undergoing or considering and is used at your own discretion.

As a medical device manufacturer, Algotec Research and Development takes patient confidentiality very seriously, so it is important that you ​​​ONLY REGISTER FOR USING THIS ALGOTEC PAIN DIARY IF: [1] you consent to the information you provide below being shared with your Pain Doctor, and [2] you consent to the information you provide below being used by Algotec in evaluating the safety and performance of the product, and to aid future research and development. 
YOUR UNIQUE ID NUMBER
I consent to this information being shared with my Pain Doctor. Indicate YES or NO
I consent to Algotec using this information for research purposes. Indicate YES or NO
Which country do you live in?
Which city do you live in?
What is your Pain Doctor's Name?
At which hospital did you have your treatment?
What is the cause of your pain?
What other treatments have you tried and how well do you feel they worked?
Your date of Birth
Your sex
How long have you had this pain?
On a scale of 0 to 10, what was your pain score immediately prior to your first PENS therapy?
How many PENS therapy treatments have you had?
What is your marital status?
Are you currently employed?
What medication are you currently taking to help control your pain?
How would you describe you pain?
What was the date of your first PENS therapy treatment?
How often do you normally have this pain? For example: Daily / Once Weekly / Once Monthly
How would you describe your general sense of well being prior to your first PENS treatment?
How did you hear about the PENS Daily Pain Diary? For example; your Doctor, company representative, internet, Algotec website
Send
​​​​​​​​​​​​​The Algotec R&D PENS therapy Pain Diary is available through our website or the Algotec PENS App which you can download from Google Play and the iStore

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