Pain Questionnaire

Name

Where do you experience pain?

What words would you use to describe your pain?

When did the pain begin?

What makes your pain worse?

What makes your pain better?

What do you do now to cope with the pain? How well do these coping strategies work for you?

What have you been told is the cause of your pain? What do you think about this?

On a scale of 0 to 10 where zero is no pain and 10 is pain as bad as you can imagine, how would you rate your average pain intensity in the past week?

How important is decreasing your daily average pain intensity to you?

On a scale of one to 10, what level of average pain intensity could you live more comfortably with?

Has your pain changed in the past six months, and if so, how so?

Describe the course of your pain throughout the day? (Ex: worse in afternoon? Better with inactivity?)

Comparing your life now to your life before the pain, what have you stopped doing completely that you used to do? Which of these activities would you like to do it again?

Comparing your life now to your life before the pain, what are you doing less of that you used to do more of? Which of these activities would you like to start doing more of again?

Are you currently not working because of pain? What was your job?

(If not working)Is returning to work a realistic goal for you? How important it is returning to work to you?

Are you currently receiving or expecting any financial compensation due to disability because of the pain? From what sources? Is there litigation in this case?

What would be an ideal outcome or set of outcomes from your perspective?

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