Study ID#_________________        Hospital#________________
               Do not write above this line
Date:____/____/____
Time:______________
Name:______________________________________________________
           Last               First           Middle Initial

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
   today?    
                  1. yes             2. no

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 past 24 hours.

_____________________________________________________________
0     1     2     3     4     5     6     7     8     9     10
No                                              Pain 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 past 24 hours.

_____________________________________________________________
0     1     2     3     4     5     6     7     8     9     10
No                                              Pain 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.

_____________________________________________________________
0     1     2     3     4     5     6     7     8     9     10
No                                              Pain 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.

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

7) What treatments or medications are you receiving for your
   pain?
_____________________________________________________________

8) In the past 24 hours, how much RELIEF have pain treatments
   or medications provided? Please circle the one percentage
   that most shows how much.

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


9) Circle the one number that describes how, during the past 24
   hours, PAIN HAS INTERFERED with your:

   A.  General Activity:
_____________________________________________________________
0     1     2     3     4     5     6     7     8     9    10  
Does not                                            Completely
interfere                                           interferes
_____________________________________________________________

   B.  Mood
_____________________________________________________________
0     1     2     3     4     5     6     7     8     9    10  
Does not                                            Completely
interfere                                           interferes
_____________________________________________________________

   C.  Walking ability
_____________________________________________________________
0     1     2     3     4     5     6     7     8     9    10  
Does not                                            Completely
interfere                                           interferes
_____________________________________________________________

   D.  Normal work (includes both work outside the home and
       housework)
_____________________________________________________________
0     1     2     3     4     5     6     7     8     9    10  
Does not                                            Completely
interfere                                           interferes
_____________________________________________________________

   E.  Relations with other people
_____________________________________________________________
0     1     2     3     4     5     6     7     8     9    10  
Does not                                            Completely
interfere                                           interferes
_____________________________________________________________

   F.  Sleep
_____________________________________________________________
0     1     2     3     4     5     6     7     8     9    10  
Does not                                            Completely
interfere                                           interferes
_____________________________________________________________

   G.  Enjoyment of life
_____________________________________________________________
0     1     2     3     4     5     6     7     8     9    10  
Does not                                            Completely
interfere                                           interferes
_____________________________________________________________

Source: Pain Research Group, Department of Neurology,
        University of Wisconsin-Madison.
Used with permission. May be duplicated and used in 
clinical practice.