NWSPM WHYMPI

WHYMPI
Name*

First NameLast Name
Date*

MonthDayYear
Date
Some of the questions in this questionnaire refer to your "significant other". This does not have to be a romantic partner. A significant other is a person with whom you feel close. This can be someone you see regularly or infrequently. It is important that you identify someone as your "significant other" in order to answer the questions in the second part of this questionnaire.
Please indicate below who your "significant other" is for the purposes of this questionnaire:

Spouse / Partner / CompanionParent / Child / Other relativeHousemate / RoommateFriend / NeighborOther
Do you live with your "significant other" identified above?
WHYMPI

Part A:
The following questions will ask you to describe your pain and how it affects your life. Please read each question carefully and then select one number on the scale under the question to indicate your answer for how that question applies to you.
1. Rate your level of pain at this present moment:*

0 - None123456 - Very Intense
2. In general, how much does your pain interfere with your day to day activities?:*

0 - None123456 - Very Much
3. Since you developed a pain problem, how much has your pain changed your ability to work?*

0 - None123456 - Very Much
4. How much has your pain changed the amount of satisfaction or enjoyment you get from participating in social or recreational activities?*

0 - None123456 - Very Much
5. How supportive or helpful is your spouse / significant other when it comes to your pain problem?*

0 - None123456 - Very Much
6. Rate your overall mood during the past week:*

0 - Extremely low123456 - Very High
7. On average, how severe has your pain been during the last week?*

0 - Extremely low123456 - Very High
8. How much has your pain changed your ability to participate in recreational and social activities?*

0 - None, not at all123456 - Very Much
9. How much has your pain changed the amount of satisfaction you get from family-related activities?*

0 - None, not at all123456 - Very Much
10. How worried about you is your spouse / significant other when it comes to your pain problem?*

0 - None, not at all123456 - Very Much
11. During the past week, how much control do you feel you have had over your life?*

0 - None, not at all123456 - Very Much
12. How much suffering do you experience because of your pain?*

0 - None, not at all123456 - Very Much
13. How much has your pain changed your marriage or other family relationships?*

0 - None, not at all123456 - Very Much
14. How much has your pain changed the amount of satisfaction or enjoyment you get from your work?*

0 - None, not at all123456 - Very Much
15. How attentive to you is your spouse or significant other when it comes to your pain?*

0 - None, not at all123456 - Very Much
16. During the past week, how well do you feel that you have been able to deal with your problems?*

0 - None, not at all123456 - Very Well
17. How much has your pain changed your ability to do household chores?*

0 - None, not at all123456 - Very Much
18. During the past week, how irritable have you been?*

0 - None, not at all123456 - Very Irritable
19. How much has your pain changed your friendships with people outside your family?*

0 - None, not at all123456 - Very Much
20. During the past week, how tense or anxious have you been?*

0 - None, not at all123456 - Very Much
WHYMPI

Part B:
In this section, we are interested in knowing how your significant other responds to you when he or she knows that you are in pain. For each question below, select only one number to indicate how your signficant other generally or typically responds to you when you are in pain.
1. Ignores me:*

0- Never123456 - Very Often
2. Asks me what she/he can do to help:*

0- Never123456 - Very Often
3. Reads to me:*

0- Never123456 - Very Often
4. Expresses irritation at me:*

0- Never123456 - Very Often
5. Takes over my jobs or duties:*

0- Never123456 - Very Often
6. Talks to me about something else to take my mind off the pain:*

0- Never123456 - Very Often
7. Expresses frustration with me:*

0- Never123456 - Very Often
8. Tries to get me to rest:*

0- Never123456 - Very Often
9. Tries to involve me in some activity:*

0- Never123456 - Very Often
10. Expresses anger at me:*

0- Never123456 - Very Often
11. Gets me some pain medications:*

0- Never123456 - Very Often
12. Encourages me to work on a hobby:*

0- Never123456 - Very Often
13. Gets me something to eat or drink:*

0- Never123456 - Very Often
14. Turns on the TV to take my mind off of the pain:*

0- Never123456 - Very Often
WHYMPI

Part C:
Listed below are 18 common activities. Please indicate how often you do each of these activities by selecting the appropriate number on the scale. Please answer all 18 items.
1. Wash dishes:*

0 - Never123456 - Very Often
2. Mow the lawn:*

0 - Never123456 - Very Often
3. Go out to eat:*

0 - Never123456 - Very Often
4. Play card games:*

0 - Never123456 - Very Often
5. Go grocery shopping:*

0 - Never123456 - Very Often
6. Work in the garden:*

0 - Never123456 - Very Often
7. Go to a movie:*

0 - Never123456 - Very Often
8. Visit friends:*

0 - Never123456 - Very Often
9. Help with house cleaning:*

0 - Never123456 - Very Often
10. Work on the car:*

0 - Never123456 - Very Often
11. Take a ride in a car:*

0 - Never123456 - Very Often
12. Visit relatives:*

0 - Never123456 - Very Often
13. Prepare a meal:*

0 - Never123456 - Very Often
14. Wash the car:*

0 - Never123456 - Very Often
15. Take a trip:*

0 - Never123456 - Very Often
16. Go to a park or a beach:*

0 - Never123456 - Very Often
17. Do a load of laundry:*

0 - Never123456 - Very Often
18. Work on needed house repairs:*

0 - Never123456 - Very Often
Interference Score
General Activity Score
Should be Empty: