Pain Questionnaire
Name
Date Of Birth
-
Month
-
Day
Year
Date
MR#
Where is your pain? Write in words or use the picture to show where you have pain
Where is your pain?
Check the words that describe your pain:
Aching
Throbbing
Shooting
Stabbing
Gnawing
Sharp
Tender
Burning
Exhausting
Tiring
Penetrating
Nagging
Numb
Miserable
Unbearable
Does your pain occur occasionally, frequently or is it constant?
Occasionally
Frequently
Constant
What time of day is your pain the worst?
Morning
Afternoon
Evening
Nighttime
Rate your pain by circling the number that best describes your pain at its worst in the last month. 0-No pain, 10- Pain as bad as you can imagine
0
1
2
3
4
5
6
7
8
9
10
Rate your pain by circling the number that best describes your pain at its least in the last month. 0-No pain, 10- Pain as bad as you can imagine
0
1
2
3
4
5
6
7
8
9
10
Rate your pain by circling the number that best describes your pain on average in the last month. 0-No pain, 10- Pain as bad as you can imagine
0
1
2
3
4
5
6
7
8
9
10
Rate your pain by circling the number that best describes your pain right now. 0-No pain, 10- Pain as bad as you can imagine
0
1
2
3
4
5
6
7
8
9
10
What makes your pain better?
What makes your pain worse?
What treatment or medication are you receiving for your pain? If you are not receiving any treatment or medication, circle NONE.
Circle the one number that describes how, during the past week, pain has interfered with your:
General Activity. 0- Does Not Interfere , 10- Completely Interferes
0
1
2
3
4
5
6
7
8
9
10
Mood 0- Does Not Interfere , 10- Completely Interferes
0
1
2
3
4
5
6
7
8
9
10
Normal Work 0- Does Not Interfere , 10- Completely Interferes
0
1
2
3
4
5
6
7
8
9
10
Sleep 0- Does Not Interfere , 10- Completely Interferes
0
1
2
3
4
5
6
7
8
9
10
Enjoyment of Life 0- Does Not Interfere , 10- Completely Interferes
0
1
2
3
4
5
6
7
8
9
10
Ability to Concentrate 0- Does Not Interfere , 10- Completely Interferes
0
1
2
3
4
5
6
7
8
9
10
Relationships with other people 0- Does Not Interfere , 10- Completely Interferes
0
1
2
3
4
5
6
7
8
9
10
Patient Signature:
Clear
Date of birth
-
Month
-
Day
Year
Date
Notes:
No action plan required.
Action plan required. See progress note.
Clinician Signature & Professional Designation
Clear
Date of Birth
-
Month
-
Day
Year
Date
Submit
Should be Empty: