10 PA Ages 18-85

Attachment 10

Pain Assessment - Ages 18-85

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Name of Test: Pain Assessment Ages 18-85
Estimated time burden: 3 minutes
On the next screens, we will ask you questions about pain. After you make your choice, the
computer will automatically go on to the next question. If you want to change your answer,
click on the Go BACK button to return to the earlier question, then choose a different answer.
Click on the CONTINUE button when you are ready to begin.
ID
PSSR18-85-01

Context/Stem
How would you rate your pain right now?

PSSR18-85-02

In the past 7 days, how would you rate your
pain on average?

PSSR18-85-03

In the past 7 days, how intense was your lowest
level of pain?

PSSR18-85-04

In the past 7 days, how intense was your pain at
its worst?

Responses
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst imaginable pain
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst imaginable pain
Had no pain
Mild
Moderate
Severe
Very severe
Had no pain
Mild
Moderate
Severe
Very severe

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
ID
PSSR18-85-05

Context/Stem
In the past 7 days, how often did your pain feel
intolerable?

PSSR18-85-06

In the past 7 days, how much did pain interfere
with your day to day activities?

PSSR18-85-07

In the past 7 days, how much did pain interfere
with work around the home?

PSSR18-85-08

In the past 7 days, how much did pain interfere
with your ability to participate in social
activities?

PSSR18-85-09

In the past 7 days, how much did pain interfere
with your household chores?

PSSR18-85-10

In the past 7 days, how much did pain interfere
with the things you usually do for fun?

PSSR18-85-11

In the past 7 days, how much did pain interfere
with your enjoyment of social activities?

Responses
Had no pain
Never
Rarely
Sometimes
Often
Always
Not at all
A little bit
Somewhat
Quite a bit
Very much
Not at all
A little bit
Somewhat
Quite a bit
Very much
Not at all
A little bit
Somewhat
Quite a bit
Very much
Not at all
A little bit
Somewhat
Quite a bit
Very much
Not at all
A little bit
Somewhat
Quite a bit
Very much
Not at all
A little bit
Somewhat
Quite a bit
Very much