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Pain Self-efficacy Questionnaire
Post-Intervention Survey
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Meer informatie
* Verplichte vraag
Personal identification number
Jouw antwoord
Where do you have pain?
Everywhere
Upper back
Lower back
Neck
Legs
Arms
Headache
Hands
Feet
Anders:
Since starting this program, have you introduced any new Complementary, Alternative or Holistic (CAM) pain control treatments?
Acupuncture
Meditation
Aromatherapy
Pain Coping Skills Training
Therapeutic Tapping
Reiki/Therapeutic touch
Yoga
I don't use these interventions
Anders:
Please indicate your confidence in the use of complementary/alternative/holistic (CAM) interventions for the management of chronic pain
Not at all confident
1
2
3
4
5
6
Completely confident
Selectie wissen
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
Selectie wissen
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
Selectie wissen
I can cope with my pain without medication.
Not at all confident
1
2
3
4
5
6
Completely confident
Selectie wissen
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
Selectie wissen
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
Selectie wissen
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
Selectie wissen
I can live a normal lifestyle, despite the pain.
Not at all confident
1
2
3
4
5
6
Completely confident
Selectie wissen
I can cope with my pain in most situations.
Not at all confident
1
2
3
4
5
6
Completely confident
Selectie wissen
I can gradually become more active, despite the pain.
Not at all confident
1
2
3
4
5
6
Completely confident
Selectie wissen
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.
Selectie wissen
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
Selectie wissen
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
Selectie wissen
Please rate your satisfaction with the Pain Coping Skills Training Program you have completed.
Not all all satisfied
1
2
3
4
5
6
Completley satisfied
Selectie wissen
Would you recommend a program such as this to a friend or family member who has pain?
Yes
No
Maybe
Selectie wissen
Please provide one word or phrase that describes your thoughts or experience in participating with this program.
Jouw antwoord
Is there anything you would like the program staff to know or consider that would make this program better for other patients?
Jouw antwoord
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