Pain Inventory Quiz

1. Where are you experiencing pain?

HeadJointNeckUpper backLower BackKneeFacial painHandLeg

2. How long have you been experiencing pain?

0-3 monthsLonger than 3 months

3. Please rate, from 1-5, how much pain has interfered with the following aspects of your life.

1 - Pain has not interfered at all
2 - Pain has interfered a little bit
3 - Pain has interfered a moderate amount
4 - Pain has interfered a great deal
5 - Pain prevents me from participating in this

A. General Activity

B. Mood

C. Walking/mobility

D. Work/Housework

E. Relationships

F. Sleep

G. Enjoyment of life

4. Are you taking any prescription pain medication for your pain?

YesNo

5. Other methods used to relieve my pain include (Please check all of that apply):

Warm compressesCold compressesRelaxation techniquesDistractionBiofeedbackHypnosisOther

Permission to contact you

Yes, please send me email updates from the Centre for Pain Care. (Your email is kept strictly confidential.)Yes, please contact me to set up an in-person pain assessment consultation.