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Profile of Chronic Pain: Screen

Severity

This assessment contains a series of questions concerning your experience with pain. It was developed for adults ages 24-80. For each question, select the response that best describes you. Please answer all questions.

1. How often during the PAST 6 MONTHS have you experienced physical pain or discomfort lasting for more than a few minutes? This could be pain from an injury or a chronic problem. It could be pain in your head, neck or back, shoulders, arms or hands, muscles or joints, stomach, feet, legs, or anywhere else in your body.

0. Never	1. Less than once a month	2. Once a month	3. Twice a month	4. Once a week	5. Several times every week	6. Daily
0. Never	1. Less than once a month	2. Once a month	3. Twice a month	4. Once a week	5. Several times every week	6. Daily

2. What was your AVERAGE level of pain on days when you had pain during the past 6 months?

	0	1	2	3	4	5	6	7	8	9	10
Very little pain	0	1	2	3	4	5	6	7	8	9	10	Unbearable pain

3. How often in the PAST 6 MONTHS have you had at least an hour’s worth of severe pain? By severe pain, we mean pain that hinders you from accomplishing your daily tasks.

0. Never	1. Less than once a month	2. Once a month	3. Twice a month	4. Once a week	5. Several times every week	6. Daily
0. Never	1. Less than once a month	2. Once a month	3. Twice a month	4. Once a week	5. Several times every week	6. Daily

4. What is the GREATEST amount of pain you have had over the PAST 6 MONTHS?

	0	1	2	3	4	5	6	7	8	9	10
Very little pain	0	1	2	3	4	5	6	7	8	9	10	Unbearable pain