Professional Documents
Culture Documents
Pain Survey Revised
Pain Survey Revised
Pain Survey Revised
Country
District Name
Setting (e.g. home, school, community center)
GPS coordinate
Section A: Patient Background
Age
<18
19-30
Gender
2-5
Occupation
<10km
Walking
Bicycle
Bus
Your own vehicle
Borrowed vehicle
Other:
Cash
Credit
Barter/trade
10-20km
31-50
>50
5-10
>10
20-30km
30-40km
Government Other:
Private insurance
>40 km
Cancer
HIV, TB or other infection
Heart problem
Diabetes
Congenital deformity
Intestinal problem
Gynecologic problem
Osteoarthritis
Rheumatologic disease
Neurologic disease
Mental health issue
Other:
Yes
No
Have you ever had pain every day that lasted for at least 6 months?
Yes
No
Yes
No
If so, for how long have you had this type of chronic, daily pain?
0-3months
If you have pain every day, is it always there or does it come and go? Always there Comes and goes
Did your pain start as a result of a specific accident, injury, trauma,
or act of violence?
If so, what was this?
Yes
No
Vehicle accident
Injury while working
Injury giving childbirth
Injury at the time of your own birth
War-related injury
Burn
Physical violence (assault)
Sexual violence
Other
Yes
No
Cancer
Congenital deformity
Infectious disease (TB, AIDS, prostatitis etc)
Rheumatic disorder (RA, lupus, Crohn's, etc)
Organ problems (liver failure, kidney stones,
uterine fibroids, hernias/intestinal issues, etc)
Strokes or other brain or spinal cord diseases
Osteoarthitis
Diabetes
Other
If so, are you receiving treatment for this underlying medical problem? Yes
(ie treatment specifically for the disease, not just for the pain)
No
Yes
No
Yes
No
0
never
3
sometimes
6
always
None
Mild
Moderate
Extreme or
cannot do
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
None
Mild
1
1
1
1
1
1
1
Moderate
2
2
2
2
2
2
2
WHO DAS
Severe
3
3
3
3
3
3
3
Severe
Extreme or
cannot do
4
4
4
4
4
4
4
5
5
5
5
5
5
5
Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches).
Have you had pain other than these kinds of everyday pain today?
1. Yes
2. No
Please rate your pain by circling the one number that best describes your pain at its worst in the last 24 hours.
0
1
2
3
4
5
6
7
8
9
10
No Pain
Pain as bad as you
can imagine
Please rate your pain by circling the one number that best describes your pain at its least in the last 24 hours.
0
1
2
3
4
5
6
7
8
9
10
No Pain
Pain as bad as you
can imagine
Please rate your pain by circling the one number that best describes your pain on the average.
0
1
2
3
4
5
6
7
8
No Pain
10
Pain as bad as you
can imagine
Please rate your pain by circling the one number that tells how much pain you have right now.
0
1
2
3
4
5
6
7
8
No Pain
10
Pain as bad as you
can imagine
In the last 24 hours, how much relief have pain treatments or medications provided? Please circle the one percentage that most
shows how much relief you have received.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
no relief
Complete relief
Copyright 1991 Charles S. Cleeland, PhD Pain Research Group All rights reserved.
Circle the one number that best describes how, during the last 24 hours, pain has interfered with your:
A.
General Activity
0
1
2
3
4
5
6
7
8
9
10
Does not
Completely
interfere
Interferes
B.
Mood
0
Does not
interfere
C.
0
Does not
interfere
10
Completely
Interferes
Walking ability
1
10
Completely
Interferes
D.
Normal Work
0
1
Does not
interfere
E.
0
Does not
interfere
F.
0
Does not
interfere
G.
0
Does not
interfere
10
Completely
Interferes
10
Completely
Interferes
Sleep
1
10
Completely
Interferes
Enjoyment of life
1
Copyright 1991 Charles S. Cleeland, PhD Pain Research Group All rights reserved.
10
Completely
Interferes
Yes
<$5
<10km
No
$5-$10
10-20km
$20-$30
30-40km
>$30
>40km
Do you (or would you) feel comfortable talking about your pain with other people in your community?
Do you think the treatment of people's pain is important?
Yes
Yes
No
No
30-40km
>40km
$10-$20
20-30km
No
10-20km
20-30km
Yes
No
Physician
Nurse
Friend or family member
Local healer
Counselor or therapist
Spiritual leader/clergy
You gave to yourself
Other:
Nothing
Pill
Acupuncture
Herbal therapy(medicine from a plant)
Movement-based therapy (stretching, yoga)
Mind-based therapy (meditation, breathing, counseling)
Procedure (injection, surgery)
Other:
<10km
10-20km
Not effective
1
20-30km
2
30-40km
3
>40km
Very effective
4
5
Check each area where you have had pain for at least 3 months.