Q.1
Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, toothaches). Have you had pain other than these everyday kinds of pain during the last week?
Yes
No
Q.2
2. With help from the diagram, describe the area(s) where you feel pain that hurts. You can state which area hurts the most.
Q.3
3. Rate your pain, on a scale of 0 to 10, that best describes your pain at its worst in the last week.
0 (no pain)
1
2
3
4
5
6
7
8
9
10 (pain as bad as you can imagine)
Q.4
4. Rate your pain, on a scale of 0 to 10, that best describes your pain at its least in the last week.
0
1
2
3
4
5
6
7
8
9
10
Q.5
5. Rate your pain, on a scale of 0 to 10, that best describes your pain on average.
0
1
2
3
4
5
6
7
8
9
10
Q.6
6. Rate your pain, on a scale of 0 to 10, on how much pain you have right now.
0
1
2
3
4
5
6
7
8
9
10
Q.7
7. What treatments or medications are you receiving for your pain?
Q.8
In the last 24 hours, how much relief have pain treatments or medications provided? Select the one percentage that most shows how much relief you have received.
0% (No relief)
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% (Complete relief)
Q.9
9. On a scale of 0 (does not interfere) to 10 (completely interferes), choose the number that describes how, during the past 24 hours, pain has interfered with your general activity:
0
1
2
3
4
5
6
7
8
9
10
Q.10
10. On a scale of 0 (does not interfere) to 10 (completely interferes), choose the number that describes how, during the past 24 hours, pain has interfered with your mood:
0
1
2
3
4
5
6
7
8
9
10
Q.11
11. On a scale of 0 (does not interfere) to 10 (completely interferes), choose the number that describes how, during the past 24 hours, pain has interfered with your walking ability:
0
1
2
3
4
5
6
7
8
9
10
Q.12
12. On a scale of 0 (does not interfere) to 10 (completely interferes), choose the number that describes how, during the past 24 hours, pain has interfered with your normal work (includes both work outside the home and housework):
0
1
2
3
4
5
6
7
8
9
10
Q.13
13. On a scale of 0 (does not interfere) to 10 (completely interferes), choose the number that describes how, during the past 24 hours, pain has interfered with your relations with other people:
0
1
2
3
4
5
6
7
8
9
10
Q.14
14. On a scale of 0 (does not interfere) to 10 (completely interferes), choose the number that describes how, during the past 24 hours, pain has interfered with your sleep:
0
1
2
3
4
5
6
7
8
9
10
Q.15
15. On a scale of 0 (does not interfere) to 10 (completely interferes), choose the number that describes how, during the past 24 hours, pain has interfered with your enjoyment of life:
0
1
2
3
4
5
6
7
8
9
10
Q.16
test