1. Throughout our lives‚ most of us have had from time to time (such as minor headaches‚ sprains‚ and toothaches). Have you had other than these everyday kinds of during the last week? 1. Yes 2. No

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

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

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

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

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

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

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

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

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

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

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

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

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

10. In the last week‚ how much relief have 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 ‚ how many hours does it take before the returns?

1. 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 .

12. Circle the appropriate answer for each item.

I believe my is due to:

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

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

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

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

· 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‚ has interfered with your:

A. General Activity