Pain Self-efficacy Questionnaire
Post-Intervention Survey
Personal identification number
Where do you have pain?
Since starting this program, have you introduced any new Complementary, Alternative or Holistic (CAM) pain control treatments?
Please indicate your confidence in the use of complementary/alternative/holistic (CAM) interventions for the management of chronic pain
Not at all confident
Completely confident
Clear selection
I can enjoy things, despite the pain *
Not at all confident
Completely confident
I can do most of the household chores(e.g. tidying-up, washing dishes, etc.),despite the pain.
Not at all confident
Completely confident
Clear selection
I can socialize with my friends or family members as often as I used to do,despite the pain.
Not at all confident
Completely confident
Clear selection
I can cope with my pain without medication.
Not at all confident
Completely confident
Clear selection
I can do some form of work, despite the pain. ('work' includes housework, paid and unpaid work)
Not at all confident
Completely confident
Clear selection
I can still do many of the things I enjoy doing, such as hobbies or leisure activity, despite pain.
Not at all confident
Completely confident
Clear selection
I can still accomplish most of my goals in life, despite the pain.
Not at all confident
Completely confident
Clear selection
I can live a normal lifestyle, despite the pain.
Not at all confident
Completely confident
Clear selection
I can cope with my pain in most situations.
Not at all confident
Completely confident
Clear selection
I can gradually become more active, despite the pain.
Not at all confident
Completely confident
Clear selection
What number best describes your pain on average in the past week?
No pain in the past week
Pain as bad as you can imagine.
Clear selection
What number best describes how, during the past week, pain has interfered with your enjoyment of life?
Does not interfere
Completely interferes
Clear selection
What number best describes how, during the past week, pain has interfered with your general activity?
Does not interfere
Completely interferes
Clear selection
Please rate your satisfaction with the Pain Coping Skills Training Program you have completed.
Not all all satisfied
Completley satisfied
Clear selection
Would you recommend a program such as this to a friend or family member who has pain?
Clear selection
Please provide one word or phrase that describes your thoughts or experience in participating with this program.
Is there anything you would like the program staff to know or consider that would make this program better for other patients?
Submit
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