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How often do you have pain?
 
Daily
 
Weekly
 
Monthly
 
Quarterly
 
Annually
 
Other
 
 
 
 
How often do you know others are having pain?
 
Daily
 
Weekly
 
Monthly
 
Quarterly
 
Annually
 
 
 
How often do you see your doctor if you have pain?
 
Weekly
 
Monthly
 
Quarterly
 
Annually
 
Not at all
 
 
 
Where is your pain?
 
Neck / arm pain
 
Back / leg pain
 
Foot pain
 
Hip / knee / other joints
 
Chest /stomach /pelvic pain
 
Headache pain
 
 
 
How long do you have to wait to see a doctor for your pain?
 
Days
 
Weeks
 
Months
 
Years
 
Not at all
 
 
 
Does your pain make you feel bad?
 
Very bad
 
somewhat bad
 
Neutral
 
Not at all
 
 
 
How long does your doctor spend with you to address your pain issue?
 
less than 5 minutes
 
less than 10 minutes
 
less than 20 minutes
 
less than 30 minutes
 
more than 30 minutes
 
 
 
How well do you understand your pain after a doctor visit?
Very confused
Somewhat confused
Neutral
Somewhat clear
Very clear
 
 
 
How satisfied are you with your pain after a doctor visit?
Very Unsatisfied
Unsatisfied
Neutral
Satisfied
Very Satisfied
 
 
 
Have you ever seen a pain specialist?
 
Yes
 
No
 
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