Pain Self-efficacy Questionnaire
Pre-Intervention Survey
Email address *
Enter your unique patient ID number
Age
Gender
Clear selection
How long have you had chronic pain?
0-3 months
4-6 months
7-12 months
1-3 years
4-6 years
7-10 years
More than 10 years
I do not have chronic pain.
Please indicate the amount of time you have had chronic pain.
Clear selection
Where do you have pain?
Why do you have pain?
How do you currently treat your pain?
If you use Complementary/Alternative/Holistic treatments, please check the ones that you have used in the past or currently use.
Please indicate your confidence in the use of complementary/alternative/holistic 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 provide one word or phrase that describes your feelings about starting this program.
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