Please respond to each question or statement by marking one box.
| PainEpisodeQ1 | In the past 12 months, how many sickle cell pain attacks (crises) did you have? …………………………….. |
|
X |
I did not have a pain attack (crises) in the past 12 months |
|
1 |
1 |
|
2 |
2 |
|
3 |
3 |
|
4 |
4 or more |
| PainEpisodeQ2 | When was your last pain attack (crisis)?…………………………………………………………………………………….. |
|
X |
I’ve never had a pain attack (crises) |
|
1 |
More than 5 years ago |
|
2 |
1-5 years ago |
|
3 |
7-11 months ago |
|
4 |
1-6 months ago |
|
5 |
1-3 weeks ago |
|
6 |
Less than a week ago |
|
7 |
I have one right now |
| PainEpisodeQ3 | Using any number from 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, how severe was your pain during your last pain attack (crisis)?………………………………………………………………………. |
|
0 |
No pain |
|
1 |
1 |
|
2 |
2 |
|
3 |
3 |
|
4 |
4 |
|
5 |
5 |
|
6 |
6 |
|
7 |
7 |
|
8 |
8 |
|
9 |
9 |
|
10 |
Worst pain imaginable |
|
X |
I’ve never had a pain attack (crisis) |
| PainEpisodeQ4 | How much did your last pain attack (crisis) interfere with your life? …………………………………………….. |
|
X |
I’ve never had a pain attack (crisis) |
|
1 |
Not at all, I did everything I usually do |
|
2 |
I had to cut down on some things I usually do |
|
3 |
I could not do most things I usually do |
|
4 |
I could not take care of myself and needed some help from family or friends |
|
5 |
I could not take care of myself and needed constant care from family, friends, doctors, or nurses |
| PainEpisodeQ5 | About how long did your most recent pain attack (crisis) last? ……………………………………………………… |
|
X |
I’ve never had a pain attack (crisis) |
|
1 |
Less than 1 hour |
|
2 |
1-12 hours |
|
3 |
13-23 hours |
|
4 |
1-3 days |
|
5 |
4-6 days |
|
6 |
1-2 weeks |
|
7 |
More than 2 weeks |