ID Individual

patient identifier
ex. 1, 2, 3, etc
Gender Male: 0
Female: 1
Age Ages 0-18: 1
Ages 19-36: 2
Ages 37-54: 3
Ages 55-72: 4
Ages 73-90: 5
Ages 90-above: 6
Location of pain Head: 1
Neck/back: 2
Upper Extremity: 3
Lower Extremity: 4
Hip: 5
Stomach: 6
Other: 7
Intensity of pain Scale of 0-10
0: no pain/ 10: worst pain
Quality of pain Pick the one that best describes your pain
Flickering, quivering, pulsing, throbbing, beating, pounding: 1
Jumping, flashing, shooting: 2
Prickling, boring, drilling: 3
Sharp, cutting, lacerating: 4
Pinching, pressing, gnawing, crushing: 5
Tugging, pulling, wrencing: 6
Hot, burning, scalding, searing: 7
Tingling, itching, stinging: 8
Dull, sore, hurting, aching, heavy: 9
Tender, taut, rasping, splitting: 10
Tiring, exhausting: 11
Sickening, suffocating: 12
Fearful, frightful, terrifying: 13
Punishing, grueling, cruel, vicious: 14
Wretched, blinding: 15
Annoying, troublesome, miserable, intense, unbearable: 16
Spreading, radiating, penetrating, piercing: 17
Tight, numb, drawing, squeezing, tearing: 18
Cool, cold, freezing: 19
Nagging, nauseating, agonizing, dreadful, torturing: 20
Short term outcome 1 My pain is better now than it was one month ago.
Strongly Agree: 1
Agree: 2
 Not sure: 3
Disagree: 4
Strongly Disagree: 5
Short term outcome 2 I am satisfied with the current treatment I am receiving for my pain.
Strongly Agree: 1
Agree: 2
Not sure: 3
Disagree: 4
Strongly Disagree: 5
Long term outcome 1 My pain is better now than it was six months ago.
Strongly Agree: 1
Agree: 2
Not sure: 3
Disagree: 4
Strongly Disagree: 5

**See "Mock up" tab below for Sample Excel Spreadsheet**