McGill Pain Questionniare (MPQ)
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Subject ID *
Initials *
Visit Number *
Ethnicity
1) How long have you had this pain?
2) Does your pain travel?
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If yes, where?
3) What is the origin/cause of your pain?
If cancer or other, please specify
4) Where does your pain occur? Shade the painful areas.
Reference regions in below picture.
5) Describe your pain.
Check one of the four categories (none, mild, moderate, severe) for each descriptor.
NONE
MILD
MODERATE
SEVERE
Throbbing
Shooting
Stabbing
Sharp
Cramping
Gnawing
Hot-Burning
Aching
Heavy
Tender
Splitting
Tiring-Exhausting
Sickening
Fearful
Punishing-Cruel
Clear selection
6) What is the amount of your overall pain?
No Pain
Worst Possible Pain
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7) How does your pain change over time?
A. Which word or words would you use to describe the pattern of your pain?
B. What relieves your pain?
C. What increases your pain?
8) Which word best describes the amount of pain you are presently feeling?
9) Has your pain affected your work schedule?
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10) Has your pain affected your sleep schedule?
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11) Has your pain affected your sexual activity?
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12) Does stress affect your pain?
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13) Is the pain affected area different from the corresponding unaffected area (ie if the pain is in the right leg, is it different from the left leg) in regard to:
Yes
No
Sweating
Temperature
Skin Sensitivity
Color
Swelling
Numbness
Clear selection
14) Do you take medications to relieve your pain?
Clear selection
If yes, write the medications and the doses you take.
15) If you have other comments regarding your pain, please write them here.
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