Pain Survey | The Rehabilitation Medicine Group

There are 5 pages of surveys to fill in (5-10 minutes).

Please fill every circle that corresponds to how you feel. There are no right or wrong answers, answer as honestly as you can.

Each survey is on a different page. They have different instructions and scales so please read the instructions for each carefully.

The completed survey will be sent to The Rehabilitation Medicine Group to be added to your file.

"*" indicates required fields

Step 1 of 5

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First name*

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Date

DD slash MM slash YYYY

Surname*

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Average pain

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BPI Interference

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Stress

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Anxiety

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Depression

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EQ5D QOL VAS

Mild D (10-13) A (8-9) S (15-18) Mod D (14-20) A (10-14) S (19-25) Sev D (21-27) A (15-19) S (26-33) Ex Sev D (28+) A (20+) S (34+)

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Pain Catastrophizing Scale

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Pain Self Efficacy Questionnaire (PSEQ)

Brief Pain Inventory

1. Please rate your pain by filling the one number that best describes your pain at its WORST in the past week.*

0 = no pain 10 = pain as bad as you can imagine

2. Please rate your pain by filling the one number that best describes your pain at its LEAST in the past week.*

0 = no pain 10 = pain as bad as you can imagine

3. Please rate your pain by filling the one number that best describes your pain on AVERAGE in the past week.*

0 = no pain 10 = pain as bad as you can imagine

4. Please rate your pain by filling the one number that tells how much pain you have RIGHT NOW.*

0 = no pain 10 = pain as bad as you can imagine

5. Fill the one number that describes how, during the past week, PAIN HAS INTERFERED with your General Activity*

0 = does not interfere 10 = completely interferes

6. Fill the one number that describes how, during the past week, PAIN HAS INTERFERED with your Mood*

0 = does not interfere 10 = completely interferes

7. Fill the one number that describes how, during the past week, PAIN HAS INTERFERED with your Walking Ability*

0 = does not interfere 10 = completely interferes

8. Fill the one number that describes how, during the past week, PAIN HAS INTERFERED with your Normal Work (includes both work outside the home and housework)*

0 = does not interfere 10 = completely interferes

9. Fill the one number that describes how, during the past week, PAIN HAS INTERFERED with your Relations with other people*

0 = does not interfere 10 = completely interferes

10. Fill the one number that describes how, during the past week, PAIN HAS INTERFERED with your Sleep*

0 = does not interfere 10 = completely interferes

11. Fill the one number that describes how, during the past week, PAIN HAS INTERFERED with your Enjoyment of life*

0 = does not interfere 10 = completely interferes

DASS 21: Please read each statement and fill a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows: 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree or a good part of time 3 Applied to me very much or most of the time

1. I found it hard to wind down*