Pain Impact Questionnaire

ACTIVITY INTERENCE
During the last month, how much did your Not at all A little bit Moderately Quite a bit Extremely
pain interfere with the following activites?
PAIN INTENSITY

1. Going to work Describe your pain on average over the last week by choosing one number from the scale below
2. Performing household chores
3. Yard work or shopping 1 2 3 4 5 6 7 8 9 10
4. Socializing with friends Mild Uncomfortable Moderate Distressingly Severe Severe Unbearable
5. Recreation and hobbies
6. Having sexual relations
Circle all of the following terms that describe your pain
7. Physical exercise
8. Sleep Prickling Aching Burning Throbbing Sharp/Stabbing Numbness/Tingling Dull Pulling Shooting Other
9. Appetite

SOCIAL SUPPORT
Social support: When you are you in pain, how often... Never Seldom Sometimes Frequently Always
Is your husband/wife/other family supportive and encouraging?
Does your husband/wife/other family ignore you or become angry?

EMOTIONAL SUPPORT
Emotional distress: During the past month, how often have you been... Never Seldom Sometimes Frequently Always
Tense or anxious?
Depressed or discouraged?
irritable and upset?