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1. Name:

2. Clinic Number:

3. In General, how satisfied are you with the quality of your life?

Always very satisfied

Almost always satisfied

Moderately satisfied

Occasionally satisfied

Never very satisfied

4. Are you currently taking narcotic pain medicine for your pain?
(includes Tylenol with codeine, Oxycontin, Vicodin, Percocet, Darvon, Darvocet, Diluadid, Methadone, MS Contin, Duragesic, Fentanyl, and other medications with morphine.)

Yes

No

5. If yes, how long have you been taking pain medicine?

6. In no, have you used narcotic pain medicine in the past?

Yes, but only immediately after surgery

Yes, but I stopped taking them

No, I have never used narctoic pain medication

7. If yes, but I stopped taking them, How long ago did you stop taking them?