In the past 4 weeks
1. How much bodily pain have you generally had during the past 4 weeks? (Circle One)
1. None
2. Very mild
3. Mild
4. Moderate
5. Severe Very severe
2. During the past 4 weeks‚ how often have you had pain or discomfort? (Circle One)
1. Once or twice
2. A few times
3. Fairly often
4. Very often
5. Every day or almost every day
3. When you had pain during the past 4 weeks‚ how long did it usually last? (Circle One)
1. A few minutes
2. Several minutes to an hour
3. Several hours
4. A day or two
5. More than two days
4. During the past 4 weeks‚ how much did pain interfere with the following things? (Circle One Number on Each Line)
1 “Not At All”‚ 2 “A Little Bit”‚ 3 “Moderately”‚ 4 “Quite A Bit”‚ 5 “Extremely”
a. Your mood
b. Your ability to walk or move about
c. Your sleep
d. Your normal work (including both work outside the home and housework)
e. Your recreational activities
f. Your enjoyment of life
5. During the past 4 weeks‚ how many days did pain interfere with the things you usually do? Your answer may range from 0 to 28 days.) WRITE IN # OF DAYS: ____________
6. Please circle the one number that best describes your pain on the average over the past 4 weeks.
No Pain 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Pain As Bad As You Can Imagine
7. Please circle the one number that best describes your pain at its worst over the past 4 weeks.
No Pain 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Pain As Bad As You Can Imagine
This instrument can be found at: www.a4ebm.org/sites/default/files/Measuring%20Health.pdf & http://www.rand.org/health/surveys_tools/mos.html
Sherbourne‚ C.D. Pain measures. In: Stewart AL‚ Ware JE‚ Jr.‚ eds. Measuring functioning and well-being: the Medical Outcomes Study approach. Durham‚ North Carolina: Duke University Press‚ 1992:220–234.
Stewart‚ A.L.‚ Ware‚ J.E Jr. (1992). Measuring functioning and well-being: the Medical Outcomes Study approach. Durham‚ North Carolina: Duke University Press‚ 374‚378–379.
McDowell‚ Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires‚ Third Edition. OXFORD UNIVERSITY PRESS