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PainQ
1
UserId
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2
This is a new way to measure how you feel... LET'S GO...
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3
How are you feeling today overall? Adjust the blue slider Left or Right...
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Row 0, Column 6
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Row 0, Column 6
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4
What is your PRIMARY source of your pain. Pick ONE. We will compare your pain with other people with the same type.
Injury / Accident
Post-Surgical
Dental
Fibromyalgia
CRPS / RSD
Migraine
Headache, not migraine
Chronic Back/Neck Pain or Disc
Arthritis
Pelvic/Abdominal Pain
Pinched Nerve
Burn
Unknown cause
Other
Injury / Accident
Post-Surgical
Dental
Fibromyalgia
CRPS / RSD
Migraine
Headache, not migraine
Chronic Back/Neck Pain or Disc
Arthritis
Pelvic/Abdominal Pain
Pinched Nerve
Burn
Unknown cause
Other
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Gender
Male
Female
I Identify As Something Else
Decline to State
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When did your pain begin?
I am not in pain
Today
This week
This month
During last 6 months
During last 12 months
During last 5 years
During last 10 years
>10 years ago
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Age
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8
How much pain are you in right now? Move the slider to pick. Left=No Pain. Right=Worst Possible Pain.
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9
Alright, making good progress... Let's keep going!
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10
Put ALL of these in order. Which do you want MOST. MOST IMPORTANT TO YOU AT TOP. Place your pain in the list.
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11
Put ALL of these in order. Which would be WORSE for you, WORST FOR YOU AT THE TOP. Place your pain in the list.
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12
Indicate how much pain you are in right now by adjusting the dial
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13
All right! You're more than half way through. Now for some DETAILS...
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14
The words below describe average pain. Please check the column that represents the degree to which you feel EACH type of pain.
0. None
1. Mild
2. Moderate
3. Severe
Throbbing
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Shooting
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Stabbing
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Sharp
Row 3, Column 0
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Row 3, Column 3
Cramping
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Gnawing
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Row 5, Column 3
Hot-Burning
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Aching
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Row 7, Column 3
Heavy
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Row 8, Column 3
Tender
Row 9, Column 0
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Row 9, Column 3
Splitting
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Row 10, Column 2
Row 10, Column 3
Tiring-Exhausting
Row 11, Column 0
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Row 11, Column 3
Sickening
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Row 12, Column 3
Fearful
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Punishing-Cruel
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Throbbing
Shooting
Stabbing
Sharp
Cramping
Gnawing
Hot-Burning
Aching
Heavy
Tender
Splitting
Tiring-Exhausting
Sickening
Fearful
Punishing-Cruel
0. None
Row 0, Column 0
1. Mild
Row 0, Column 1
2. Moderate
Row 0, Column 2
3. Severe
Row 0, Column 3
0. None
Row 1, Column 0
1. Mild
Row 1, Column 1
2. Moderate
Row 1, Column 2
3. Severe
Row 1, Column 3
0. None
Row 2, Column 0
1. Mild
Row 2, Column 1
2. Moderate
Row 2, Column 2
3. Severe
Row 2, Column 3
0. None
Row 3, Column 0
1. Mild
Row 3, Column 1
2. Moderate
Row 3, Column 2
3. Severe
Row 3, Column 3
0. None
Row 4, Column 0
1. Mild
Row 4, Column 1
2. Moderate
Row 4, Column 2
3. Severe
Row 4, Column 3
0. None
Row 5, Column 0
1. Mild
Row 5, Column 1
2. Moderate
Row 5, Column 2
3. Severe
Row 5, Column 3
0. None
Row 6, Column 0
1. Mild
Row 6, Column 1
2. Moderate
Row 6, Column 2
3. Severe
Row 6, Column 3
0. None
Row 7, Column 0
1. Mild
Row 7, Column 1
2. Moderate
Row 7, Column 2
3. Severe
Row 7, Column 3
0. None
Row 8, Column 0
1. Mild
Row 8, Column 1
2. Moderate
Row 8, Column 2
3. Severe
Row 8, Column 3
0. None
Row 9, Column 0
1. Mild
Row 9, Column 1
2. Moderate
Row 9, Column 2
3. Severe
Row 9, Column 3
0. None
Row 10, Column 0
1. Mild
Row 10, Column 1
2. Moderate
Row 10, Column 2
3. Severe
Row 10, Column 3
0. None
Row 11, Column 0
1. Mild
Row 11, Column 1
2. Moderate
Row 11, Column 2
3. Severe
Row 11, Column 3
0. None
Row 12, Column 0
1. Mild
Row 12, Column 1
2. Moderate
Row 12, Column 2
3. Severe
Row 12, Column 3
0. None
Row 13, Column 0
1. Mild
Row 13, Column 1
2. Moderate
Row 13, Column 2
3. Severe
Row 13, Column 3
0. None
Row 14, Column 0
1. Mild
Row 14, Column 1
2. Moderate
Row 14, Column 2
3. Severe
Row 14, Column 3
1
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15
How much does your pain PREVENT YOU FROM DOING each thing:
0. Little/No impact
1. Some Trouble
2. Very Challenging
3. Cannot AT ALL
Sleeping
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Row 0, Column 2
Row 0, Column 3
Walking
Row 1, Column 0
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Row 1, Column 2
Row 1, Column 3
Running
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Reading
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Thinking clearly
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Working
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Lifting heavy objects
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Row 6, Column 3
Picking up light objects
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Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Feeling happy
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Friendships / connecting
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Feeling good about myself
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Feeling good about my future
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Sleeping
Walking
Running
Reading
Thinking clearly
Working
Lifting heavy objects
Picking up light objects
Feeling happy
Friendships / connecting
Feeling good about myself
Feeling good about my future
0. Little/No impact
Row 0, Column 0
1. Some Trouble
Row 0, Column 1
2. Very Challenging
Row 0, Column 2
3. Cannot AT ALL
Row 0, Column 3
0. Little/No impact
Row 1, Column 0
1. Some Trouble
Row 1, Column 1
2. Very Challenging
Row 1, Column 2
3. Cannot AT ALL
Row 1, Column 3
0. Little/No impact
Row 2, Column 0
1. Some Trouble
Row 2, Column 1
2. Very Challenging
Row 2, Column 2
3. Cannot AT ALL
Row 2, Column 3
0. Little/No impact
Row 3, Column 0
1. Some Trouble
Row 3, Column 1
2. Very Challenging
Row 3, Column 2
3. Cannot AT ALL
Row 3, Column 3
0. Little/No impact
Row 4, Column 0
1. Some Trouble
Row 4, Column 1
2. Very Challenging
Row 4, Column 2
3. Cannot AT ALL
Row 4, Column 3
0. Little/No impact
Row 5, Column 0
1. Some Trouble
Row 5, Column 1
2. Very Challenging
Row 5, Column 2
3. Cannot AT ALL
Row 5, Column 3
0. Little/No impact
Row 6, Column 0
1. Some Trouble
Row 6, Column 1
2. Very Challenging
Row 6, Column 2
3. Cannot AT ALL
Row 6, Column 3
0. Little/No impact
Row 7, Column 0
1. Some Trouble
Row 7, Column 1
2. Very Challenging
Row 7, Column 2
3. Cannot AT ALL
Row 7, Column 3
0. Little/No impact
Row 8, Column 0
1. Some Trouble
Row 8, Column 1
2. Very Challenging
Row 8, Column 2
3. Cannot AT ALL
Row 8, Column 3
0. Little/No impact
Row 9, Column 0
1. Some Trouble
Row 9, Column 1
2. Very Challenging
Row 9, Column 2
3. Cannot AT ALL
Row 9, Column 3
0. Little/No impact
Row 10, Column 0
1. Some Trouble
Row 10, Column 1
2. Very Challenging
Row 10, Column 2
3. Cannot AT ALL
Row 10, Column 3
0. Little/No impact
Row 11, Column 0
1. Some Trouble
Row 11, Column 1
2. Very Challenging
Row 11, Column 2
3. Cannot AT ALL
Row 11, Column 3
1
of 12
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16
Which of the rating methods did you like best / seemed like the best way to communicate how much pain you're experiencing? You can pick more than one if you really liked several...
Pain Sound
0-10 scale / slider
Compare pain to negatives (like sunburn)
Compare pain relief to good things (like freedom to travel)
Pain dial
Description words (sickening, burning...)
What pain keeps you from (sleeping, walking...)
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17
CONGRATULATIONS!! All done. Hope you'll come back again soon! CLICK SUBMIT TO COMPLETE!
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Paintone
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Calibration
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