ISLAND HEALTH REGIONAL PAIN PROGRAM
PATIENT QUESTIONNAIRE
Please complete the following questionnaire to help us understand your complex pain
problem. The information you provide is part of your medical file and, as such, is subject
to confidentiality.
Please tick appropriate boxes wherever indicated.
I. PATIENT INFORMATION
Date Questionnaire
Completed
Full Name
Street
Address City
Postal Code
Home Phone #
( )
Cell Phone # ( )
Work Phone # ( )
May we contact you at work? Yes No
Email address No Yes:
Birth Date (dd/mm/yyyy)
Age
Gender Male Female
Family Physician
BC Care Card #
Emergency Contact
Name:
Phone # ( )
Their relationship to you:
Do you have an open
claim related to your pain
problem?
Tick all that apply:
WorkSafe BC Claim # _____________
ICBC Claim # _____________
Canada Disability Pension Claim # _____________
Other Claim # _____________
I have not submitted any claims
Are you currently involved
in a formal legal suit
related to your pain
problem?
Yes No
Island Health Regional Pain Program, updated 6/2015 Page 1 of 24
II. PAIN HISTORY
1. Please describe the pain problem that brings you to this clinic:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
2. When did your pain first start? Please be as exact as possible.
Day [ ] Month [ ] Year [ ]
3. How did your pain begin? Check ONE
; if more than one applies, check the one that
applies the best.
Accident at work
At work, but not involving an accident
Accident at home
Car accident
After surgery
After an illness
Pain just began, no clear reason
Other reasons (please describe) ______________________________________
________________________________________________________________
________________________________________________________________
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III. TREATMENT HISTORY
1. Have you already been assessed by any medical specialists for your pain problem?
No Yes: Please list:
Name of Specialist Specialty (if known)
Date of
Assessment
2. Have you ever been treated by any of the following disciplines for your pain problem?
How helpful was the treatment?
Discipline
Result
When was this
treatment?
Helpful
No change
Anesthesiology
Neurosurgery
Orthopedic surgery
Rheumatology
Psychology
Psychiatry
Physiotherapy
Occupational Therapy
Chiropractic
Acupuncture
Massage Therapy
Social Worker
Other Pain Clinic
3. Have you had any Medical Imaging done? (i.e. X-ray, CAT scan, MRI, Ultrasound)
No Yes: Please list:
Type of Image
Where was the image taken?
Date
Island Health Regional Pain Program, updated 6/2015 Page 3 of 24
IV. PAIN DIAGRAM
Please shade or label on the body chart where you currently experience your symptoms.
(If you wish, you may use the symbols in the KEY to describe
different sensations.)
KEY
////// Ache
sss Stiffness
xxx Burning
=== Numbness
ooo Pins &
Needles
www Swelling
Island Health Regional Pain Program, updated 6/2015 Page 4 of 24
V. CURRENT PAIN
1. How intense is your pain at this moment? (Circle the appropriate number.)
0 1 2 3 4 5 6 7 8 9 10
No Pain Worst Pain
2. What were the highest and lowest levels of your pain in the last week? (Make 2 circles.)
0 1 2 3 4 5 6 7 8 9 10
No Pain Worst Pain
3. What makes your pain worse? (You may check more than one choice.)
Sitting
Bending
Walking
Driving
Standing
Everything
Cold weather
Sex
Lying down
Loud noise
Hot weather
Stress
Lifting
Working
Wet weather
Tension
Household
chores
Going up/down
stairs
Weather
changes
Any movement
Other:
________________________________________________________________
4. What makes your pain better? (You may check more than one choice.)
Sitting
Medication
Cold weather
Sex
Standing
Watching TV
Hot weather
Alcohol
Lying down
Working
Pressure
Rest
Stretching
Hot/cold packs
Massage/rubbing
Nothing
Relaxing
Warm/hot bath
Walking
Keeping busy
Reading
Sleeping
Warm/hot
shower
Being with others
Keeping my mind
off it
Other:
(Describe)
________________________________________________________________
5. How long can you comfortably:
Sit __________________________
Stand __________________________
Walk __________________________
Sleep __________________________
6. How much time during the day do you spend off your feet (lying down, sleeping,
watching TV?) __________________________________________________________
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7. Sleep:
(a) During the past month, how often have you had trouble sleeping because of
pain?
Not during the past month
Once or twice a week
Less than once a week
Three or more times a week
(b) During the last month, how many hours of actual sleep did you get at night? (This
may be different than the number of hours you spent in bed.)
Hours Of Sleep/Night _____________________
(c) During the past month, how would you rate your overall sleep quality?
Very good
Fairly bad
Fairly good
Very bad
8. Associated features:
If you have pain in your arms or legs, do you have:
Increase sweating in the hand or foot?
Temperature changes in the hand or foot
Colour changes in the hand or foot
Swelling in the hand or foot
Increased sensitivity to touch in the arm or leg
9. Do you have a history of:
Cancer
Weight loss in the past 6 months
Night sweats/fevers in the past 6 months
Island Health Regional Pain Program, updated 6/2015 Page 6 of 24
VI. IF YOU HAVE LOW BACK PAIN, PLEASE ANSWER THE FOLLOWING QUESTIONS
(If not, skip to Section VII.)
1. Have you had back surgery? Yes No (If No, please skip to Question 3.)
2. If yes, and you have continued back pain, please answer the following questions:
(a) What were your symptoms (what were you feeling) before your surgery:
Back pain
Leg pain: left right
Back and leg pain
(b) How long did you wait from the time your back pain began to the time you had
your surgery? ___________________
(c) Since your back surgery, are you:
Better
Worse
The same
(d) Date of surgery:
1
st
_____________ Surgeon _____________________
2
nd
_____________ Surgeon _____________________
3
rd
_____________ Surgeon _____________________
3.
Which is more painful:
Bending forwards
Leaning backwards
4. Do you have weakness in your legs? Yes No
5. Do you have any bowel or bladder problems? Yes No
6. Which is worse? Back pain Leg pain Both are equal
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7. ROLAND MORRIS QUESTIONNAIRE:
When your back hurts, you may find it difficult to perform many activities throughout the
day. Statements listed below have been used by people to describe those times when
they are experiencing back pain. As you read them, some may stand out because they
describe your pain today.
Please check the boxes next to the statements that best describe your pain today. If the
statement does not apply, just leave it blank and move on to the next one.
I stay at home most of the time because of my back.
I change positions frequently to try to get my back comfortable.
I walk more slowly than usual because of my back.
Because of my back, I am not doing any of the jobs that I usually do around the house.
Because of my back, I use a handrail to walk upstairs.
Because of my back, I lie down to rest more often.
Because of my back, I have to hold on to something to get out of my chair.
Because of my back, I try to get other people to do things for me.
I get dressed more slowly than usual because of my back.
I only stand up for short periods of time because of my back.
Because of my back, I try not to bend or kneel down.
I find it difficult to get out of a chair because of my back.
My back is painful almost all the time.
I find it difficult to turn over in bed because of my back.
My appetite is not very good because of my back pain.
I have trouble putting on my socks or stockings because of my back.
I only walk short distances because of my back pain.
I don't sleep well because of my back.
Because of my back pain, I get dressed with help from someone else.
I sit down for most of the day because of my back.
I avoid heavy jobs around the house because of my back.
Because of my back pain, I am more irritable and bad tempered with people than usual.
Because of my back pain, I walk upstairs more slowly than usual.
I stay in bed most of the time because of my back.
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VII. IF YOU HAVE NECK PAIN
, PLEASE ANSWER THE FOLLOWING QUESTIONS
(If not, skip to Section VIII.)
1. Have you had neck surgery? Yes No (If No, please skip to Question 3.)
2. If Yes:
(a) What were your symptoms (what were you feeling) before your surgery:
Neck pain
Arm pain: left right
Neck and arm pain
(b) How long did you wait from the time your neck pain began to the time you had your
surgery? _____________________
(c) Since your neck surgery, are you:
Better
Worse
The same
(d) Date of surgery:
1st
_____________ Surgeon _____________________
2
nd
_____________ Surgeon _____________________
3
rd
_____________ Surgeon _____________________
3. With respect to your neck pain, which is more painful:
Looking up
Looking down
Looking left
Looking right
4. Do you have weakness in your hands/arms? Yes No
5. Do you have numbness in your hands/arms? Yes No
6. Which is worse: neck pain arm pain both are equal
Island Health Regional Pain Program, updated 6/2015 Page 9 of 24
7. The following questions are designed to help us better understand how your neck pain
affects your ability to manage everyday life activities. Please mark in each section, the
one box that applies to you. Although you may consider that two of the statements in
any one section relate to you, please mark the box that most closely describes your
present-day situation.
a) Pain intensity
I have no pain at the moment.
The pain is very mild at the moment.
The pain is moderate at the moment.
The pain is fairly severe at the moment.
The pain is very severe at the moment.
The pain is the worst imaginable at the moment.
b) Personal care
I can look after myself normally without causing extra pain.
I can look after myself normally, but it causes extra pain.
It is painful to look after myself, and I am slow and careful.
I need some help, but manage most of my personal care.
I need help every day in most aspects of self-care.
I do not get dressed. I wash with difficulty and stay in bed.
c) Lifting
I can lift heavy weights without causing extra pain.
I can lift heavy weights, but it gives me extra pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if
items are conveniently positioned, i.e. on a table.
Pain prevents me from lifting heavy weights, but I can manage light weights if
they conveniently positioned.
I can lift only very light weights.
I cannot light or carry anything.
d) Work (occupational and/or personal)
I can do as much work as I want.
I can only do my usual work, but no more.
I can do most of my usual work, but no more.
I can’t do my usual work.
I can hardly do any work at all.
I cannot do any work at all.
e) Concentration
I can concentrate fully without difficulty.
I can concentrate fully with slight difficulty.
I have a fair degree of difficulty concentrating.
I have a lot of difficulty concentrating.
I have a great deal of difficulty concentrating.
I can’t concentrate at all.
Island Health Regional Pain Program, updated 6/2015 Page 10 of 24
f) Sleeping
I have no trouble sleeping.
My sleep is slightly disturbed for less than 1 hour.
My sleep is slightly disturbed for up to 1-2 hours.
My sleep is slightly disturbed for up to 2-3 hours.
My sleep is slightly disturbed for up to 3-5 hours.
My sleep is slightly disturbed for up to 5-7 hours.
g) Driving
I can drive my car without neck pain.
I can drive as long as I want with slight neck pain.
I can drive as long as I want with moderate neck pain.
I can’t drive as long as I want because of moderate neck pain.
I can hardly drive at all because of severe neck pain.
I can’t drive my car at all because of neck pain.
h) Reading
I can read as much as I want with no neck pain.
I can read as much as I want with slight neck pain.
I can read as much as I want with moderate neck pain.
I can’t read as much as I want because of moderate neck pain.
I can’t read as much as I want because of severe neck pain.
I can’t read at all because of severe neck pain.
i) Headaches
I have no headaches at all.
I have slight headaches that come infrequently.
I have moderate headaches that come infrequently.
I have moderate headaches that come frequently.
I have severe headaches that come frequently.
I have headaches almost all the time.
j) Recreation
I have no neck pain during all recreational activities.
I have some neck pain with all recreational activities.
I have some neck pain with a few recreational activities.
I have neck pain with most recreational activities.
I can hardly do recreational activities due to neck pain.
I can’t do any recreational activities due to neck pain.
Island Health Regional Pain Program, updated 6/2015 Page 11 of 24
VIII. IF YOU HAVE HEADACHES, PLEASE ANSWER THE FOLLOWING QUESTIONS.
(If not, skip to Section IX.)
1. Have you seen a neurologist for headaches?
No Yes: (Name)____________________________________________________
2. What medications are you taking for headaches?
______________________________________________________________________
______________________________________________________________________
3. Do you have any warning signs before your headaches, such as flashing lights, smells,
visual problems, increasing neck pain etc.? Yes No
If yes, describe: ________________________________________________________
______________________________________________________________________
4. Do you have associated nausea and/or vomiting? Yes No
5. Do noises or bright lights bother you during a headache? Yes No
6. How long do your headaches last? _________________________________________
7. How often do you get a severe headache? ___________________________________
8. What do you do when you have a bad headache? _____________________________
9. Please mark the best response:
a) I have a headache:
1x per month 2-4x per month More than 1x per week
b) My headaches typically are:
Mild Moderate Severe
10. The purpose of the following scale* is to identify difficulties that you may be experiencing
because of your headache. Please check-off “Yes”, “Sometimes”, or “No” to each item.
Answer each question as it pertains to your headache, only.
Island Health Regional Pain Program, updated 6/2015 Page 12 of 24
Some-
Yes times No
E1 Because of my headaches I feel handicapped.
F2
Because of my headaches I feel restricted in performing routine daily
activities.
E3 No one understands the effect my headaches have on my life.
F4 I restrict recreational activities (sports, hobbies) because of headaches.
E5 My headaches make me angry.
E6 Sometimes I feel I am going to lose control because of my headaches.
F7 Because of my headaches, I am less likely to socialize.
E8
My spouse (significant other) or family and friends have no idea what I’m
going through because of my headaches.
E9 My headaches are so bad that I think I am going to go insane.
E10 My outlook on the world is affected by my headaches.
E11 I am afraid to go outside when I feel that a headache is starting.
E12 I feel desperate because of my headaches.
F13
I am concerned that I am paying penalties at work or at home because of
my headaches.
E14 My headaches place stress on my relationships with family or friends.
F15 I avoid being around people when I have a headache.
F16 I believe my headaches make it difficult to achieve my goals in life.
F17 I am unable to think clearly because of my headaches.
F18 I get tense (muscle tension) because of my headaches.
F19 I do not enjoy social gatherings because of my headaches.
E20 I feel irritable because of my headaches.
F21 I avoid traveling because of my headaches.
E22 My headaches make me feel confused.
E23 My headaches make me feel frustrated.
F24 I find it difficult to read because of my headaches
F25
I find it difficult to focus my attention away from my headaches and on other
things.
*Jackson GP, Ramadan NM, et al. The Henry Ford Hospital headache disability inventory (HDI). Neurology 1994; 44:837-842
Island Health Regional Pain Program, updated 6/2015 Page 13 of 24
IX. EXPECTATIONS
1. Based on your experiences so far, what do you realistically expect will happen to your
pain in the coming months? (Check one)
My pain will get worse.
My pain will not change.
My pain will be completely relieved or cured.
2. What do you believe is the cause of your pain?
______________________________________________________________________
______________________________________________________________________
3. If your pain could be reduced, but not completely, how much of a reduction would there
need to be for you to feel you could live with it? _______%
4. Do you think your pain may be due to a serious disease, which doctors have not found
or have not told you about? Yes No Not sure
X. MEDICATIONS
1. Please list any allergies you might have. (Include over the counter and herbal
medications.)
______________________________________________________________________
______________________________________________________________________
2. Do you think you need pain medication, or stronger pain medication, than you are
currently taking? (Circle the appropriate number.)
1 2 3 4 5
______________________________________________________________
Agree Agree Unsure Disagree Disagree
Strongly Strongly
3. What medications are you currently taking for your pain?
Drug Name
Dosage
How
often?
Date
Started
Side Effects? Is it Effective?
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Island Health Regional Pain Program, updated 6/2015 Page 14 of 24
4. What medications have you tried in the past for your pain but have stopped using?
Drug Name
Were there side
effects?
Was it effective?
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
5. What medications do you take for other health conditions?
Drug Name
Dosage
How
often?
Date
Started
Side Effects? Is it Effective?
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
6. Opiate History: Opiate (narcotic) medications include: Codeine, Morphine,
Hydromorphone (Dilaudid), Oxycodone (Percocet, Endocet), Tramadol
(Tramacet), and Fentanyl patch.
Please ask if you are not sure if your medication is an opiate.
(a) I AM currently taking OPIATE medication.
Yes: Please answer the following questions.
No: Please skip to Question 7.
(b) Please tell us about the opiate prescription you are currently taking:
Drug Name
How many tablets
are in a
prescription?
How many days
are there
between refills?
Island Health Regional Pain Program, updated 6/2015 Page 15 of 24
(c) Do you have any of the following side effects?
Nausea
Itching
Sweating
Stomach irritation
Constipation
Difficulty urinating
Intoxication
Drowsiness
Confusion
Loss of sex drive
Other:
(d) Which doctor(s) currently prescribes this medication? _____________________
(e) Which pharmacy dispenses this medication to you?
_________________________
(f) How long does each prescription usually last?
______________________________
(g) PLEASE DO NOT BE OFFENDED BY THE FOLLOWING QUESTIONS. THEY
ARE ROUTINE QUESTIONS ASKED OF EVERYONE ON OPIATE
MEDICATIONS:
Yes No
Have you ever sold, or attempted to sell, or give these medications
to anyone else?
Have you ever bought, or attempted to buy, any of these
medications from anyone other than the pharmacy?
Have you ever been involved in illegal drug use?
Have you ever stolen, forged, or attempted to steal or forge a
prescription?
Have you ever injected, smoked, or attempted to inject or smoke
any of these medications?
Does your activity increase when you take these medications?
Do you use these medications for anything other than pain relief?
If yes, please explain: _________________________________________________
___________________________________________________________________
___________________________________________________________________
7. Drug and Alcohol History:
(a) Do you smoke cigarettes/cigars? Yes No
(b) Do you smoke, or have you smoked marijuana? Yes No
Island Health Regional Pain Program, updated 6/2015 Page 16 of 24
(c) Do you drink alcohol? Yes No
If yes:
1) How many days/week do you drink? _____________________
2) How many drinks do you have on the days you do drink? ________________
3) Do you drink alcohol to relieve your pain? Yes No
4) Have you ever tried to cut down? Yes No
5) Do you get Angry when people comment on your drinking? Yes No
6) Do you feel Guilty about your drinking? Yes No
7) Do you ever need an “Eye opener” in the morning? Yes No
(d) Have you ever had a problem with drug abuse? Yes No
If yes, please give details: ______________________________________
___________________________________________________________
___________________________________________________________
(e) Has anyone in your family had a problem with drugs or alcohol? Yes No
Explain: _________________________________________________________
________________________________________________________________
________________________________________________________________
XI. PAIN IMPACT
Briefly describe the IMPACT your pain problem has had on you with respect to:
Mood:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Ability to socialize:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Island Health Regional Pain Program, updated 6/2015 Page 17 of 24
Affect on your relationship with your spouse, family, and friends:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
How would you describe your quality of life?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
XII. OCCUPATION HISTORY
1. What is your usual occupation?
______________________________________________________________________
2. What is your current employment status? Tick all that apply.
Employed full-time
Employed part-time
Unemployed, not planning on
returning to work
Unemployed, looking for work
Unemployed, disabled
Retired, due to pain
Retired, not due to pain
3. What is your current source of income? Tick all that apply.
Wage / salary
Workers’ Compensation
Pension
Spouse’s income
Unemployment benefits
Social assistance
Disability benefits Other:
4. If you are employed, is your work limited due to pain? Yes No
5. If you are employed, have you taken time off due to pain in the last year? Yes No
If yes, how much time? ___________________________________________________
6. If you are unemployed now, do you have a job to return to? Yes No
7. If you are unemployed now, have you attempted to return to work? Yes No
Island Health Regional Pain Program, updated 6/2015 Page 18 of 24
XIII. PSYCHOSOCIAL HISTORY
1. What is your marital status?
Married Common-Law
Divorced Separated
Single Widowed
2. How many children do you have? __________
3. Do you live:
Alone With your spouse and children
With children only With other relatives
With spouse With friends
4. What is your highest level of education?
Grade ____ College
University Other _________________________________
5. Do you know anyone with a chronic pain problem? Yes No
If yes, please describe the nature of their relationship to you:
______________________________________________________________________
______________________________________________________________________
6. Do you have a history of depression, anxiety, or any other psychiatric/psychological
problems? Yes No
If yes, is this directly related to your pain problem? Yes No
7. Are you currently taking medication for depression or anxiety? Yes No
8. Have you ever been suicidal? Yes No
If yes, is this directly related to your pain problem? Yes No
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XIV. MEDICAL/SURGICAL HISTORY
1.
Do you currently have any of the following conditions? Tick all that apply.
Heart disease
Lung disease
Diabetes
Stroke
Blood clotting problems
Weakness in your arms or legs
Bowel problems
Bladder problems
Weight loss in the past 6 months
Night sweats/fevers in the last 6 months
Cancer If yes, what type?
________________________________
2. List by year (starting at childhood), as best you can, all illnesses and operations you
have had previously.
Year
Surgical Operation
(e.g. Back Fusion)
Year
Medical Illness
(e.g. Measles, diabetes)
3. What questions would you like answered after your assessment at this pain clinic?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Island Health Regional Pain Program, updated 6/2015 Page 20 of 24
PAIN OUTCOMES QUESTIONNAIRE
We ask that all patients regardless of condition complete the remainder of the questionnaire.
I. INSTRUCTIONS:
Please circle the number
that best describes the question being asked.
Choose only 1 number per question.
1) Enter today’s date: _____/_____/________ (dd/mm/yyyy)
2) On a scale of 0 to 10, with 0 being no pain at all and 10 being the worst possible pain,
how would you rate your pain on average during the past week?
No Pain
0 1 2 3 4 5 6 7 8 9 10
Worst Possible Pain
3) Does your pain interfere with your ability to walk?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
4) Does your pain interfere with your ability to carry/handle everyday objects such as a
bag of groceries or books?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
5) Does your pain interfere with your ability to climb stairs?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
6) Does your pain require you to use a cane, walker, wheelchair, or other devices?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
7) Does your pain interfere with your ability to bathe yourself?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
8) Does your pain interfere with your ability to dress yourself?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
9) Does your pain interfere with your ability to use the bathroom?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
10) Does your pain interfere with your ability to manage your personal grooming (for
example, combing your hair, brushing your teeth, etc.)?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
Island Health Regional Pain Program, updated 6/2015 Page 21 of 24
11) Does your pain affect your self-esteem or self-worth?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
12) How would you rate your physical activity?
Significant
limitation
in basic
activities
0 1 2 3 4 5 6 7 8 9 10
Can perform
vigorous activities
without limitation
13) How would you rate your overall energy?
Totally
worn out
0 1 2 3 4 5 6 7 8 9 10
Most energy ever
14) How would you rate your strength and endurance today?
Very poor
0
1
2
3
4
5
6
7
8
9
10
Very high
15) How would you rate your feelings of depression today?
Not at all
depressed
0 1 2 3 4 5 6 7 8 9 10
Extremely depressed
16) How would you rate your feelings of anxiety today?
Not at all
anxious
0 1 2 3 4 5 6 7 8 9 10
Extremely anxious
17) How much do you worry about re-injuring yourself if you are more active?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
18) How safe do you think it is for you to exercise?
Not safe at
all
0 1 2 3 4 5 6 7 8 9 10
Extremely safe
19) Do you have problems concentrating on things today?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
20) How often do you feel tense?
Not at all
0
1
2
3
4
5
6
7
8
9
10
All the time
Island Health Regional Pain Program, updated 6/2015 Page 22 of 24
II. PATIENT SPECIFIC FUNCTIONAL SCALE
Step 1: Pick one to three activities that are important to you, which you cannot perform,
or have difficulty doing now as a result of your pain.
Step 2: Please circle one number that best rates your ability to perform the activity now.
Activity 1:
0 1 2 3 4 5 6 7 8 9 10
Unable Able to Perform
To Perform Activity at Pre-
Activity
problem Level
Activity 2:
0 1 2 3 4 5 6 7 8 9 10
Unable Able to Perform
To Perform Activity at Pre-
Activity
problem Level
Activity 3:
0 1 2 3 4 5 6 7 8 9 10
Unable Able to Perform
To Perform Activity at Pre-
Activity
problem Level
Island Health Regional Pain Program, updated 6/2015 Page 23 of 24
III. PASS 20
Individuals who experience pain develop different ways to respond to that pain. We would like
to know what you do and what you think about when in pain. Please use the rating scale below
to indicate how often you engage in each of the following thoughts or activities.
Circle one number from 0 (NEVER) to 5 (ALWAYS) for each item.
NEVER ALWAYS
1.
I think that if my pain gets too severe, it will never
decrease.
0 1 2 3 4 5
2.
When I feel pain, I am afraid that something
terrible will happen.
0 1 2 3 4 5
3.
I go immediately to bed when I feel severe pain.
0 1 2 3 4 5
4.
I begin trembling when engaged in activity that
increases pain.
0 1 2 3 4 5
5.
I can’t think straight when I am in pain.
0 1 2 3 4 5
6.
I will stop any activity as soon as I sense pain
coming on.
0 1 2 3 4 5
7.
Pain seems to cause my heart to pound or race.
0 1 2 3 4 5
8.
As soon as pain comes on, I take medication to
reduce it.
0 1 2 3 4 5
9.
When I feel pain, I think that I may be seriously ill.
0 1 2 3 4 5
10.
During painful episodes, it is difficult for me to
think of anything else besides the pain.
0 1 2 3 4 5
11.
I avoid important activities when I hurt.
0 1 2 3 4 5
12.
When I sense pain I feel dizzy or faint.
0 1 2 3 4 5
13.
Pain sensations are terrifying.
0 1 2 3 4 5
14.
When I hurt I think about the pain constantly.
0 1 2 3 4 5
15.
Pain makes me nauseous (feel sick to my
stomach).
0 1 2 3 4 5
16.
When pain comes on strong I think I might
become paralyzed or more disabled.
0 1 2 3 4 5
17.
I find it hard to concentrate when I hurt
0 1 2 3 4 5
18.
I find it difficult to calm my body down after
periods of pain.
0 1 2 3 4 5
19.
I worry when I am in pain.
0 1 2 3 4 5
20.
I try to avoid activities that cause pain.
0 1 2 3 4 5
Thank you for completing this questionnaire.
It will help us to better understand your pain problem.
Island Health Regional Pain Program, updated 6/2015 Page 24 of 24
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