adent #: DALLAS PAIN QUESTIONNAIRE Name: Date of Birth: Todays Date: Examiner: Please read carefully: This questionnaire has been designed fo give your doctor information as to how your pain has attected your lle. ‘Be sure that these are your answers. Do not ask somgone else fo fil out the questionnaire for you. Please mark an “X" in the appropriate ‘box that expresses your thoughts from 1 to 100 in each section. Section |: Pain and intensity “To what degree do you raly oh pain medications or pain relieving Section IX: Traveling How much does pain imerfere with traveling ina car? substances for you to be coronable? Nene ‘Soma | cannot None Some ‘Almotime Same as belore travel te (ee FEET F-eTS--e -CE=L PEEPS vo C0 (rece Ferd PEt Seer ee aE 0 Section I: Personal Care ‘Section X: Vocations! ‘How much does pain interfere wih your personal care (geting out of bed, How much does pain interfere wih your job? tooth Brushing essing, oe)? None Some | eannot None Some Ieannat get Noinieerence work ‘oa pain) ‘outa bod 0% ( tot Dit 100% om f 1 | | | 100% Section X: AnxletyIMood Section Mt: Liting How much contol do you fel thet you have over demands made on you? ow mach imtaben do you notice in iting? (80 chango) Some None None ‘Some Feannot kt Total (can wt 38 anying 100% ( 0% oe EEE T T 9 100% a ection xi: Emational Contra nV: Walking fow mach contol do you Tel hat you have over your emotions? Compared io how fr you could walk bere your inky or back wouble, me None how much does pan reste your waking now? enero) = Icanwak. ‘Almost the Very leant te sane came a walk 100% ( (ee 0% | | | | 1 } 100% Section xil: Depression Seer How depressed have you been since the onset of pain? Section V: Siting Not deprassed Overwhelmed Back pain iis my siting in a char to? ea by depression ono, pin Some tama x “ONY aa same as belore zal on( (ela } 100% }100% Section XIV: Interpersonal Relationships 0% ( I I ‘Section VE: Standing How much do yeu ink your pain has changed your relatonships wih How much does you" pain interere wth your tolerance to standtor long Wok, peroas? eats None Some Feannat same as botore pion fae Cd ee [eee bed, } 100% Section XV: Social Support om much support do you ned om otro halp you ding tis onset Section vi: Sleeping apa (aking over chores, ning meals)? ow much does pain nterer wth your seeping? foe fae None Some leannet needed time hme as bole sloop ata 0% ( I I 1) 100% 0% ( I I | I ) 100% Section XVI: Punishing Reaponaes Section Vil Sota Lie Hew much do you tink tore xpress iain, satin or anger How much does pain itetere wih your social ite (dancing, games, going toward you becauso of ou pa? out ening wih none, 27> None Some Atthe None some No activo me tame as betre ‘alos om Tt T_T _) 100% 100%. PEER SEE Eee eee aoe eee a