Pain Questionnaire to be evaluated

Attachment 1 – Questions to be evaluated OMB #0920-0222; Expiration Date: 06/30/2015

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

1. How would you rate your current health?

   1. Excellent

   2. Very Good

   3. Good

   4. Fair

   5. Poor

2. Do you have any chronic illnesses?

   1. Yes

   2. No

3. Do you feel any pain or ache right now, at this very moment?

   1. Yes

   2. No

4. HOW LONG have you had your current pain problem?

1. Less than 1 month

2. 1–3 months

3. 3–6 months

4. 6 months–1 year

5. More than 1 year

6. More than 5 years

5. In the past 7 days, how would you rate your pain on average? With zero being no pain and 10 being the worst pain you’ve ever felt?

0-10 _______________

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

   1. Not at all

   2. A little bit

   3. Somewhat

   4. Quite a bit

   5. Very much

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

   1. Not at all

   2. A little bit

   3. Somewhat

   4. Quite a bit

   5. Very much

8. How often during the PAST 6 MONTHS have you experienced pain or discomfort lasting for more than a few minutes? This could be pain from an injury or a chronic problem. It could be pain in your head, neck or back, shoulders, arms or hands, muscles or joints, stomach, legs, or anywhere else in your body.

   1. Never

   2. Almost Never

   3. Somewhat

   4. Often

   5. Almost Always

9. How often in the PAST 6 MONTHS have you had at least an hour’s worth of SEVERE pain? By severe pain, we mean pain that hinders you from accomplishing your daily tasks.

   1. Never

   2. Almost Never

   3. Somewhat

   4. Often

   5. Almost Always

10. What is the GREATEST amount of pain you have had over the PAST 6 MONTHS? With zero being no pain and 10 being the worst pain you’ve ever felt?

0-10 _______________

11. Have you been on sick leave due to pain during the past six months?

    1. Yes

    2. No

12. How often, if ever, in the past 6 months, have you had to give up enjoyable activities, such as hobbies, going to the movies, or fun activities with friends or family because of your pain?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

13. How often, if ever, in the past 6 months, have you not been able to fulfill your usual and expected responsibilities at home, such as chores, repair work, or cleaning because you were in pain?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

14. How often, if ever, in the past 6 months, have you not been able to enjoy your relationships with your spouse or significant other, family, or friends because of your pain?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

15. How often, if ever, in the past 6 months, have you not been able to pursue personal goals because of your pain?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

16. How often, if ever, in the past 6 months, have you been unable to provide basic care for yourself, such as get out of the bed, dress yourself, shower alone, prepare meals, eat without assistance, fix your hair, put on cosmetics, or shave because of your pain?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

17. How often, if ever, in the past 6 months have you been unable to think clearly, solve problems, concentrate, or remember accurately because of your pain?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

18. How often over the past 6 months has your pain caused you to feel sad or depressed?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

19. How often over the past 6 months has your pain caused you to feel tense, anxious, or jittery?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

20. How often over the past 6 months has your pain caused you to feel angry?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

21. How often over the past 6 months has your pain caused you to feel isolated or lonely?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

22. How often over the past 6 months has your pain reduced your ability to enjoy your life?

    1. Never

    2. Almost Never

    3. Somewhat

    4. Often

    5. Almost Always

23. Which treatment has helped you best?

__________________________

24. How often do you use analgesics prescribed by a physician?

    1. Daily

    2. Weekly

    3. monthly

    4. a few times a year

    5. never

25. How often do you use over-the-counter (nonprescription) analgesics?

    1. Daily

    2. Weekly

    3. monthly

    4. a few times a year

    5. never

26. Due to your pain(s), have you had to take higher doses of medicines than prescribed or instructed on the package?

1. Yes

2. No

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