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Please complete the consent form 48 hours prior to your appointment

Pain Questionnaire

This form mirrors the official PDF and will download a filled copy for testing.

How did your main pain begin?
How long has your main pain been present?
Tick one box only
Which statement best describes your pain?
Tick one box only
Do you have any of the following?
In particular specify if you have:
Health care (other than your visits to the pain clinic)
Section 2 — Your work
If yes answer the remainder of section 2
(tick one only, then go straight to Section 3)
During the past seven days, how much did your pain affect your productivity while you were working?
Choose a number from 0 (no effect) to 10 (completely prevented working).
Section 3 — Medication use
Medicine name
Strength
Per day
Days per week
Section 4 — Pain intensity and interference

Shade in ALL the areas where you feel pain.

Tip: drag to draw, hold Alt/Option to erase.
On the diagram below, put an X on the ONE area that hurts most
Please rate your pain by circling the one number that best describes the following:
0 — No pain10 — Pain as bad as you can imagine
Your pain at its worst in the last week?
Your pain at its least in the last week?
Your pain on average?
How much pain do you have right now?
During the past week, how much has pain interfered with the following:
0 — Does not interfere10 — Completely interferes
012345678910
Your general activity?
Your mood?
Your walking ability?
Your normal work (both outside the home and housework)?
Your relations with other people?
Your sleep?
Your enjoyment of life?
Section 5 — DASS21

Please read each statement and circle 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.

  • 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 the time
  • 3 — Applied to me very much, or most of the time
1. I found it hard to wind down
2. I was aware of dryness of my mouth
3. I couldn’t seem to experience any positive feeling at all
4. I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion)
5. I found it difficult to work up the initiative to do things
6. I tended to overreact to situations
7. I experienced trembling (e.g. in the hands)
8. I felt that I was using a lot of nervous energy
9. I was worried about situations in which I might panic and make a fool of myself
10. I felt that I had nothing to look forward to
11. I found myself getting agitated
12. I found it difficult to relax
13. I felt down-hearted and blue
14. I was intolerant of anything that kept me from getting on with what I was doing
15. I felt I was close to panic
16. I was unable to become enthusiastic about anything
17. I felt I wasn’t worth much as a person
18. I felt that I was rather touchy
19. I was aware of the action of my heart in the absence of physical exertion (e.g. a sense of heart rate increase, heart missing a beat)
20. I felt scared without any good reason
21. I felt that life was meaningless
Section 6 — PSEQ (Pain Self-Efficacy Questionnaire)

Rate how confident you are that you can do the following things at present despite the pain. Circle one of the numbers on the scale under each item, where 0 = Not at all confident and 6 = Completely confident.

Remember this questionnaire is not asking whether or not you have been doing these things, but rather how confident you are that you can do them at present, despite the pain.

  • 0 — Not at all confident
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6 — Completely confident
1. I can enjoy things, despite the pain
2. I can do most of the household chores (e.g. tidying up, washing dishes, etc.) despite the pain
3. I can socialise with my friends or family members as often as I used to do, despite the pain
4. I can cope with my pain in most situations
5. I can do some form of work, despite the pain (“work” includes housework, paid and unpaid work)
6. I can still do many of the things I enjoy doing, such as hobbies or leisure activity, despite the pain
7. I can cope with my pain without medication
8. I can still accomplish most of my goals in life, despite the pain
9. I can live a normal lifestyle, despite the pain
10. I can gradually become more active, despite the pain
Section 7 — PCS

Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery.

We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.

0 — Not at all1 — To a slight degree2 — To a moderate degree3 — To a great degree4 — All the time
1. I worry all the time about whether the pain will end
2. I feel I can’t go on
3. It’s terrible and I think it’s never going to get any better
4. It’s awful and I feel it overwhelms me
5. I feel I can’t stand it anymore
6. I become afraid that the pain will get worse
7. I keep thinking of other painful events
8. I anxiously want the pain to go away
9. I can’t seem to keep it out of my mind
10. I keep thinking about how much it hurts
11. I keep thinking about how badly I want the pain to stop
12. There’s nothing I can do to reduce the intensity of the pain
13. I wonder whether something serious may happen