Please enter your name
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Please enter your date of birth
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Throughout most of our lives we have had pain from time to time (such as minor headache, sprains, toothache). Have you had pain, other than these everyday kinds of pain during the last week?
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Yes
No
Please rate your pain by selecting the number that best describes your pain at its worst in the last 24 hours. 0 is no pain at all. 10 is the worst pain you can imagine.
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Please rate your pain by selecting the number that best describes your pain at its least in the last 24 hours. 0 is no pain at all. 10 is the worst pain you can imagine.
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Please rate your pain by selecting the number that best describes your pain on the average. 0 is no pain at all. 10 is the worst pain you can imagine.
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Please rate your pain by selecting the number that best describes your pain right now. 0 is no pain at all. 10 is the worst pain you can imagine.
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Please rate your pain by selecting the number that best describes your pain right now. 0 is no pain at all. 10 is the worst pain you can imagine.
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What treatments or medications are you receiving for your pain?
In the past week, how much relief have pain treatments or medications provided? Please select the number that most shows how much relief you have received? 0 is no relief. 10 is complete relief.
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Please select the number that describes how, during the past week, pain has interfered with your:
General activity. 0 means it does not interfere, 10 means completely interferes.
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Mood. 0 means it does not interfere, 10 means completely interferes.
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Walking ability. 0 means it does not interfere, 10 means completely interferes.
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Normal work (including outside the home and housework). 0 means it does not interfere, 10 means completely interferes.
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Relationships with other people. 0 means it does not interfere, 10 means completely interferes.
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Sleep. 0 means it does not interfere, 10 means completely interferes.
* Required0 1 2 3 4 5 6 7 8 9 10
Enjoyment of life. 0 means it does not interfere, 10 means completely interferes.
* Required0 1 2 3 4 5 6 7 8 9 10
