1. Have you experienced pain on most days in the past 3 months? *
YesNo

2. Select the number that best describes your pain on average over the past week. *
0 - No Pain12345678910-Worst Possible Pain

3. On the body map, please indicate all areas where you have had pain over the past week. Mark an “X” on each area where you have had any pain.

Mark “yes” to the following items that describe your pain over the past week and “no” to the ones that do not.

4. Did the pain feel like pins and needles? *
YesNo

5. Did the pain feel hot/burning? *
YesNo

6. Did the pain feel numb? *
YesNo

7. Did the pain feel like electrical shocks? *
YesNo

8. Is the pain made worse with the touch of clothing or bed sheets? *
YesNo

9. Is the pain limited to your joints? *
YesNo

Questions 10-12 ask about how much your pain may or may not have interfered with various aspects of your life in the past week. Thinking about the past week, select the number that best describes how much your pain has interfered with your…

10. Usual activities (such as daily routine, walking, leisure or social activities, work, housework, self-care)? *
0 - Not at All12345678910-Completely Interferes

11. Sleep? *
0 - Not at All12345678910-Completely Interferes

12. Mood? *
0 - Not at All12345678910-Completely Interferes

13. Did you have trouble thinking or remembering in the past week? *
0 - No Problem12345678910-Severe Problem

14. Were you sensitive to such things as bright lights, or loud noises, or smells in the past week? *
0 - No Problem12345678910-Severe Problem