Questionnaire for Grading Severity of Chronic Pain

 

Questions [text slightly modified from Appendix, page 147]

(1) How would you rate your pain on a 0-10 scale at the present time (right now)? [Pain Right Now]

• responses 0 to 10

• 0 = no pain

• 10 = pain as bad as it could be

(2) During the past 6 months, how intense was your worst pain? [Worst Pain]

• responses 0 to 10

• 0 = no pain

• 10 = pain as bad as it could be

(3) During the past 6 months, on the average, how intense was your pain? (That is, your usual pain at times you were experiencing pain.) [Average Pain]

• responses 0 to 10

• 0 = no pain,

• 10 = pain as bad as it could be

(4) About how many days in the past 6 months have you been kept from your usual activities (work, school or housework) because of your pain? [Disability Days]

• response the total number of days disabled

• points assigned below

5) In the past 6 months, how much has the pain interfered with your daily activities? [Daily Activities]

• responses 0 to 10

• 0 = no interference

• 10 = unable to carry on any activities

(6) In the past 6 months, how much has the pain changed your ability to take part in recreational, social and family activities? [Social Activities]

• responses 0 to 10

• 0 = no change

• 10 = extreme change

(7) In the past 6 months, how much has the pain changed your ability to work (including housework)? [Work Activities]

• responses 0 to 10

• 0 = no change

• 10 = extreme change

 

characteristic pain intensity =

= (((response question 1) + (response question 2) + (response question 3)) / 3) * 10

 

disability score =

= (((response question 5) + (response question 6) + (response question 7)) / 3) * 10

 

disability points =

= (points for disability days) + (points for disability score)

Parameter	Finding	Points
disability days from question 4	0 - 6 days	0
	7 - 14 days	1
	15 - 30 days	2
	>= 31 days	3
disability score (above)	0 - 29	0
	30 - 49	1
	40 - 69	2
	>= 70	3

 

Interpretation

 

Findings	Type	Grade
no pain problems for the prior 6 months	pain free	0
characteristic pain intensity < 50 disability points < 3	low disability, low intensity	I
characteristic pain intensity >= 50 disability points < 3	low disability, high intensity	II
disability points 3 or 4	high disability, moderately limiting	III
disability points 5 or 6	high disability, severely limiting	IV