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Pain Self-efficacy Questionnaire
Pre-Intervention Survey
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* Indicates required question
Email
*
Your email
Enter your unique patient ID number
Your answer
Age
Your answer
Gender
Female
Male
Prefer not to say
Other:
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.
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?
Everywhere
Upper back
Lower back
Neck
Legs
Arms
Headache
Hands
Feet
Other:
Why do you have pain?
Arthritis
Fibromylagia
Degenerative disc disease
Chronic headache or migraine
Chronic Regional Pain Syndrome (CRPS or RSD)
Spine disorder
Other:
How do you currently treat your pain?
Interventional procedures (epidural steroid injections, pain pump, stimulator, trigger point injections or other pain management procedure provided in the pain management office)
Opioid medication (medicine such as morphine, oxycodone, fentanyl or other controlled medicines)
Non-opioid prescribed medication (medications other than opioids that are prescribed for you)
Non-opioid over the counter medications (medicines you do not need a prescription for such as Tylenol, Motrin, Aleve)
Non-medicine medical treatments such as TENS unit, physical therapy, ice, heat
Complementary/Alternative/Holistic treatments (Acupuncture, Reiki, Aromatherapy, Meditation, Tapping, Guided Imagery ect)
Psychological interventions such as Cognitive Behavioral Therapy or Acceptance and Commitment Therapy
Other:
If you use Complementary/Alternative/Holistic treatments, please check the ones that you have used in the past or currently use.
Acupuncture
Meditation
Aromatherapy
Pain Coping Skills Training
Therapeutic Tapping
Reiki/Therapeutic touch
Yoga
Other:
Please indicate your confidence in the use of complementary/alternative/holistic interventions for the management of chronic pain
Not at all confident
1
2
3
4
5
6
Completely confident
Clear selection
I can enjoy things, despite the pain
*
Not at all confident
1
2
3
4
5
6
Completely confident
I can do most of the household chores(e.g. tidying-up, washing dishes, etc.),despite the pain.
Not at all confident
1
2
3
4
5
6
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
1
2
3
4
5
6
Completely confident
Clear selection
I can cope with my pain without medication.
Not at all confident
1
2
3
4
5
6
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
1
2
3
4
5
6
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
1
2
3
4
5
6
Completely confident
Clear selection
I can still accomplish most of my goals in life, despite the pain.
Not at all confident
1
2
3
4
5
6
Completely confident
Clear selection
I can live a normal lifestyle, despite the pain.
Not at all confident
1
2
3
4
5
6
Completely confident
Clear selection
I can cope with my pain in most situations.
Not at all confident
1
2
3
4
5
6
Completely confident
Clear selection
I can gradually become more active, despite the pain.
Not at all confident
1
2
3
4
5
6
Completely confident
Clear selection
What number best describes your pain on average in the past week?
No pain in the past week
0
1
2
3
4
5
6
7
8
9
10
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
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
Clear selection
What number best describes how, during the past week, pain has interfered with your general activity?
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
Clear selection
Please provide one word or phrase that describes your feelings about starting this program.
Your answer
Submit
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