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Pain and Stress Questionnaire

          Copyright © 1996 Adaptive Behavior Centers Inc. All rights reserved.

        (child questions/responses are in parentheses)

1. The level of pain or stress discomfort in % I experienced this week was:

 10

 25

 40

 55

 70

 85

 100

2. The amount of pain or stress medication in % I took this week was:

 0

 15

 30 or none prescribed

 50

 75

 100

 Over 100

3. At the present time, what is your level of pain or stress discomfort?

 None

 Slight

 Very little

 Mild severity

 Severe

 Very severe

 Extremely severe

4. I experienced the following level of tension / anxiety this week:

 None

 Slight

 Very little

 Mild intensity

 Intense

 Very intense

 Extremely intense

5. My general mood during the past week was:

 Very happy

 Happy

 Not sad

 Sad

 Depressed

 Very depressed

 Exremely depressed

6. How much did pain or stress disturb your sleep last week?

 None

 Slight

 Very little

 Mild

 Much

 Very much

 Extreme disturbance

Copyright © 1996 Adaptive Behavior Centers Inc. All rights reserved.

7. The beneficial effect of prescribed therapeutic activities during the past week was:

 Extremely effective

 Very effective

 Effective or no activities prescribed

 Moderate

 Mild

 Minimal

 No effect at all

8. How much did pain or stress interfere with completing moderate exercises?

 None

 Slight

 Very little

 Mild

 Much interference or no exercise

 Very much interference

 Extreme interference

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Pain and Stress Questionnaire

          Copyright © 1996 Adaptive Behavior Centers Inc. All rights reserved.

        (child questions/responses are in parentheses)

9. How much did you enjoy sex (playtime) this week?

 Extreme enjoyment

 Very much

 Much

 Mildly

 Very little

 Slightly or no sex (playtime) this week

 No enjoyment

10. How much food did you consume this week?

 Adequate amount for healthy fitness

 Slightly more than adequate

 Adequate only

 More or less than adequate

 Much more or less than adequate

 Very much more or less than adequate

 Extremely too much or too little

11. How did your significant other respond to your suffering during the past week?

 Minimal sympathy

 Slight sympathy

 Very little sympathy

 Mild sympathy

 Much sympathy

 Very much sympathy

 Extreme sympathy

12. How helpful is your clinician/provider with your pain or stress?

 Extremely helpful

 Very much

 Much

 Mild

 Very little

 Slight

 No help

Copyright © 1996 Adaptive Behavior Centers Inc. All rights reserved.

13. How confident were you in your therapeutic program last week?

 Extremely confident

 Very much confident

 Much confidence

 Mild confidence

 Very little confidence

 Slight confidence

 No confidence

14. How much did pain/stress affect your social life this week?

 No effect

 Slightly

 Very little

 Mild

 Much inability to participate

 Very much unable to participate

 Extremely unable to participate

15. How much did pain/stress affect your ability to resume work/normal lifestyle (school)?

 No effect

 Slightly

 Very little

 Mild

 Much inability to work (or attend school)

 Very much unable to work (or attend school)

 Extremely unable to work (or attend school)

16. How much did pain or stress affect your ability to concentrate?

 No effect

 Slightly

 Very little

 Mild

 Much inability to concentrate

 Very much unable to concentrate

 Extremely unable to concentrate

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Pain and Stress Questionnaire

          Copyright © 1996 Adaptive Behavior Centers Inc. All rights reserved.

        (child questions/responses are in parentheses)

17. How much did pain or stress affect your memory this week?

 No effect

 Slightly

 Very little

 Mild

 Much

 Very much

 Extreme

18. How much did you practice prescribed therapeutic techniques last week?

 More than prescribed

 Slightly more than prescribed

 Adequate as prescribed or none

 Less

 Much less

 Very much less

 Extremely less than prescribed

Copyright © 1996 Adaptive Behavior Centers Inc. All rights reserved.

19. My ability to control my pain or stress using prescribed intervention techniques was:

 I was able to totally control my pain/stress

 I was more than partially able to control my pain/stress

 Moderate or no intervention

 Mild

 Very little

 Slight

 No control

20. My ability to control my pain or stress using prescribed medication last week was:

 I was able to totally control my pain/stress

 I was more than partially able to control my pain/stress

 Moderate or no medication prescribed

 Mild

 Very little

 Slight

 No control

21. The number of alcoholic drinks (caffienated beverages) I had during the past week was:

 None

 1 - 2

 3 - 5

 Daily

 2 a day

 3 a day

 More than 3 a day

22. The number of cigarettes I smoked (amount of candy consumed) during the past week was:

 None

 1 or 2 per day (few pieces of candy)

 3 - 5 per day (several pieces of candy)

 Half a pack per day (2 large candy bars)

 1 pack per day (3 large candy bars)

 2 packs per day (4 large candy bars)

 Chain smoking (eating candy all day daily)

23. How much do you desire to return to work / normal life style (school)?

 Extreme desire

 Much

 Moderate

 Mild

 Very little

 Slight

 No desire

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Pain and Stress Questionnaire

          Copyright © 1996 Adaptive Behavior Centers Inc. All rights reserved.

        (child questions/responses are in parentheses)

24. How much do you fear pain or stress?

 No fear

 Slightly fearful

 Very little

 Mild fear

 Moderate fear

 Much fear

 Extreme fear

Copyright © 1996 Adaptive Behavior Centers Inc. All rights reserved.

25. How much do you blame yourself for your pain or stress?

 No blame

 Slight

 Very little

 Mild

 Much

 Very much

 Extreme

26. How much do you understand your pain or stress?

 Completely understand

 Comprehend very much

 Comprehend much

 Minimal understanding

 Little understanding

 Very little understanding

 Not at all

27. How much does pain or stress affect personal grooming or routine daily chores?

 No effect

 Slight

 Very little

 Mild

 Much difficulty

 Very much difficulty

 Extreme difficulty

28. How much do you think you can cope with your pain or stress?

 Very much

 Much

 Moderate

 Mild

 Very little

 Slightly

 Not at all

29. How enduring do you think your pain or stress will be?

 Not enduring

 Slightly enduring

 Endure very little

 Enduring

 Very enduring

 Very much enduring

 Will last forever

30. How much does your pain/stress involve disability income or financial loss (to you or your parents/guardian)?

 No involvement

 Slightly

 Very little

 Mild

 Much

 Very much

 Extreme

Patient/Client/Research Subject_________________________________________Date:_________________

Doctor/Therapist/Researcher________________________________________     Date:__________            _ 

Copyright © 1996 Adaptive Behavior Centers Inc. All rights reserved.