Pain Survey

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

This field is for validation purposes and should be left unchanged.
Stress
Anxiety
Depression
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+)
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