1. 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 everyday kinds of pain during the last week? 1. Yes 2. No

IF YOU ANSWERED YES TO THIS QUESTION‚ PLEASE GO ON TO QUESTION 2 AND FINISH THIS QUESTIONNAIRE. IF NO‚ YOU ARE FINISHED WITH THE QUESTIONNAIRE. THANK YOU.

2. On the diagram‚ shade in the areas where you feel pain. Put an X on the area that hurts the most.

3. Please rate your pain by circling the one number that best describes your pain at its worst in the last week.

No Pain 0 1 2 3 4 5 6 7 8 9 10 as bad as Pain you can imagine

4. Please rate your pain by circling the one number that best describes your pain at its least in the last week.

No Pain 0 1 2 3 4 5 6 7 8 9 10 as bad as Pain you can imagine

5. Please rate your pain by circling the one number that best describes your pain on the average.

No Pain 0 1 2 3 4 5 6 7 8 9 10 as bad as Pain you can imagine

6. Please rate your pain by circling the one number that tells how much pain you have right now.

No Pain 0 1 2 3 4 5 6 7 8 9 10 as bad as Pain you can imagine

7. What kinds of things make your pain feel better (for example‚ heat‚ medicine‚ rest)?

8. What kinds of things make your pain worse (for example‚ walking‚ standing‚ lifting)?

9. What treatments or medications are you receiving for your pain?

10. In the last week‚ how much relief have pain treatments or medications provided? Please circle the one percentage that most shows how much relief you have received.

No Relief 0% 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100% Complete Relief

11. If you take pain medication‚ how many hours does it take before the pain returns?

1. Pain medication doesn’t help at all.

2. One hour.

3. Two hours.

4. Three hours.

5. Four hours.

6. Five to twelve hours.

7. More than twelve hours.

8. I do not take pain medication.

12. Circle the appropriate answer for each item.

I believe my pain is due to:

1. The effects of treatment (for example‚ medication‚ surgery‚ radiation‚ prosthetic device). (Yes‚ No)

2. My primary disease (meaning the disease currently being treated and evaluated). (Yes‚ No)

3. A medial condition unrelated to primary disease (for example‚ arthritis). (Yes‚ No)

13. For each of the following words‚ check yes or no if that adjective applies to your pain.

· Aching (Yes‚ No)

· Throbbing (Yes‚ No)

· Shooting (Yes‚ No)

· Stabbing (Yes‚ No)

· Gnawing (Yes‚ No)

· Sharp (Yes‚ No)

· Tender (Yes‚ No)

· Burning (Yes‚ No)

· Exhausting (Yes‚ No)

· Tiring (Yes‚ No)

· Penetrating (Yes‚ No)

· Nagging (Yes‚ No)

· Numb (Yes‚ No)

· Miserable (Yes‚ No)

· Unbearable (Yes‚ No)

14. Circle the one number that describes how‚ during the past week‚ pain has interfered with your:

A. General Activity