LinkId Text Cardinality Type Description & Constraints mypainquestionnaire Questionnaire A questionnaire to use with the MyPAIN application for a patient to assess their pain levels, locations, and treatments for use in consultation with a clinician to determine further treatments. 1 My Pain Location. We’d like to ask you a few questions about your pain and how it is affecting your life. Please describe the location(s) of any pain you have had in the past 7 days. 0..1 group 1.1 Head. What type of HEAD pain? 0..1 choice Options: 6 options 1.2 Neck. What type of NECK pain? 0..1 choice Options: 6 options 1.3 Shoulders. What type of SHOULDERS pain? 0..1 choice Options: 6 options 1.4 Arms. What type of ARMS pain? 0..1 choice Options: 6 options 1.5 Upper Back. What type of UPPER BACK pain? 0..1 choice Options: 6 options 1.6 Lower Back. What type of LOWER BACK pain? 0..1 choice Options: 6 options 1.7 Hands. What type of HANDS pain? 0..1 choice Options: 6 options 1.8 Abdomen. What type of ABDOMEN pain? 0..1 choice Options: 6 options 1.9 Pelvis. What type of PELVIS pain? 0..1 choice Options: 6 options 1.10 Hips. What type of HIPS pain? 0..1 choice Options: 6 options 1.11 Upper Legs. What type of UPPER LEGS pain? 0..1 choice Options: 6 options 1.12 Knees. What type of KNEES pain? 0..1 choice Options: 6 options 1.13 Lower Legs. What type of LOWER LEGS pain? 0..1 choice Options: 6 options 1.14 Feet. What type of FEET pain? 0..1 choice Options: 6 options 1.15 Everywhere. What type of EVERYWHERE pain? 0..1 choice Options: 6 options 1.16 Other, please describe. Other, please describe 0..1 text 2 My Pain Intensity. Thinking about your overall pain, in the past 7 days, please respond to the questions below: 0..1 group 2.1 How intense was your pain at its worst? 0..1 choice Options: 5 options 2.2 How intense was your average pain? 0..1 choice Options: 5 options 2.3 What is your level of pain right now? 0..1 choice Options: 5 options 3 My Pain Interference. Thinking about your overall pain, in the past 7 days, please respond to the questions below: 0..1 group 3.1 How much did pain interfere with your day to day activities? 0..1 choice Options: 5 options 3.2 How much did pain interfere with your work around the home? 0..1 choice Options: 5 options 3.3 How much did pain interfere with your ability to participate in social activities? 0..1 choice Options: 5 options 3.4 How much did pain interfere with your household chores? 0..1 choice Options: 5 options 4 My Pain Interference. Thinking about your overall pain, in the past 7 days, please respond to the questions below: 0..1 group 4.1 How much did pain interfere with the things you usually do for fun? 0..1 choice Options: 5 options 4.2 How much did pain interfere with your enjoyment of social activities? 0..1 choice Options: 5 options 4.3 How much did pain interfere with your enjoyment of life? 0..1 choice Options: 5 options 4.4 How much did pain interfere with your family life? 0..1 choice Options: 5 options 5 About My Treatments. We’d like to know more about how you manage your pain and what has worked for you. When answering these questions, please focus on pain related to what brings you in for your upcoming medical visit. These treatments are organized into sections by type: Basic therapies Mind-body therapies New therapies Non-prescription medicines Prescription medicines 0..1 display 6 About My Treatments. What have you tried in the past 6 months to help you with your pain? Select all answers that apply. We also want to know if it worked for you. 0..1 group 6.1 Exercises at home (such as those assigned by a therapist) or outside (such as walking, jogging, swimming). Did it work? 0..1 choice Options: 3 options 6.2 Sleep positioners or devices (such as additional pillows, padding, etc.). Did it work? 0..1 choice Options: 3 options 6.3 Stretching. Did it work? 0..1 choice Options: 3 options 6.4 Weight loss or changes in your diet. Did it work? 0..1 choice Options: 3 options 6.5 Setting and reaching activity goals. Did it work? 0..1 choice Options: 3 options 6.6 Ice or Heat Therapy. Did it work? 0..1 choice Options: 3 options 6.7 Physical Therapy. Did it work? 0..1 choice Options: 3 options 6.8 Acupuncture. Did it work? 0..1 choice Options: 3 options 6.9 Chiropractic treatment. Did it work? 0..1 choice Options: 3 options 6.10 Other, please describe. Other, please describe 0..1 text 7 About My Treatments. Have you used any of the following items you can buy without a prescription from your doctor to help with your pain in the last 6 months (select all that apply)? 0..1 group 7.1 Pain relievers (such as Advil, Aleve, Aspirin, Ibuprofen, Motrin, Tylenol). Did it work? 0..1 choice Options: 3 options 7.2 Herbal or nutritional pain relievers (such as ginseng or kava kava). Did it work? 0..1 choice Options: 3 options 7.3 Cremes, lotions, gels or patches applied to the skin (for example BENGAY®, TIGER BALM® or BiOFREEZE®). Did it work? 0..1 choice Options: 3 options 7.4 Other items you can buy without a prescription from your doctor, please describe. Other, please describe 0..1 text 8 About My Treatments. Have you used any of the following prescription medications to help with your pain in the last 6 months? 0..1 group 8.1 Opioid medications (such as hydrocodone, oxycodone, codeine, morphine and fentanyl). Did it work? 0..1 choice Options: 3 options 8.2 Procedure or Injection (such as a shot to relieve inflammation). Did it work? 0..1 choice Options: 3 options 8.3 Non-opioid medications as prescribed by a doctor (such as Celebrex or Cymbalta). Did it work? 0..1 choice Options: 3 options 8.4 Medical marijuana. Did it work? 0..1 choice Options: 3 options 8.5 Other, please describe. Other, please describe 0..1 text 9 About My Treatments. Have you tried any of the following new therapies to help with your pain in the last 6 months (select all that apply)? 0..1 group 9.1 Yoga. Did it work? 0..1 choice Options: 3 options 9.2 Massage. Did it work? 0..1 choice Options: 3 options 9.3 Meditation. Did it work? 0..1 choice Options: 3 options 9.4 Relaxation or mindfulness-based training. Did it work? 0..1 choice Options: 3 options 9.5 Group or individual therapy for pain. Did it work? 0..1 choice Options: 3 options 9.6 Cognitive behavioral therapy. Did it work? 0..1 choice Options: 3 options 9.7 Acceptance or commitment therapy. Did it work? 0..1 choice Options: 3 options 9.8 Sleep management (such as a sleep study or CPAP). Did it work? 0..1 choice Options: 3 options 9.9 Other, please describe. Other, please describe 0..1 text 10 About My Treatments. Have you tried any of the following new therapies to help with your pain in the last 6 months (select all that apply)? 0..1 group 10.1 Aromatherapy. Did it work? 0..1 choice Options: 3 options 10.2 Crystals. Did it work? 0..1 choice Options: 3 options 10.3 Essential oils. Did it work? 0..1 choice Options: 3 options 10.4 CBD oil. Did it work? 0..1 choice Options: 3 options 10.5 Music therapy. Did it work? 0..1 choice Options: 3 options 10.6 Other, please describe. Other, please describe 0..1 text 11 About My Goals. We’d like to know more about you and your goals. What are your most important activity goals? For example: I’d like to be able to walk without pain. 0..1 text 12 About My Goals. What are the biggest barriers to achieving your activity goals? For example: I have a lot of stress from work which makes my pain worse. 0..1 text 13 Managing Chronic Pain. Below is a link to a video produced by the American Chronic Pain Association about living with chronic pain. We’d like to suggest you watch the video to help you prepare for your upcoming visit. This video can help you prepare to ask questions that are important to you when you visit with your provider. 0..1 text 14 Managing Chronic Pain. The website linked below provides some information from the U.S. Pain Foundation about the causes and diagnosis of pain in general, treatment options and self management and well-being when living with pain. This information can help you prepare to ask questions that are important to you when you visit with your provider. 0..1 text 15 MyPAIN Feedback. Please indicate your level of agreement with the following statement: 0..1 group 15.1 Using the MyPAIN tool has helped me begin preparing for a conversation with my provider about managing my pain. 0..1 choice Options: 5 options 16 MyPAIN Feedback. Do you have any other feedback or thoughts to share on your use of MyPAIN? 0..1 text Documentation for this format
A questionnaire to use with the MyPAIN application for a patient to assess their pain levels, locations, and treatments for use in consultation with a clinician to determine further treatments.
Please describe the location(s) of any pain you have had in the past 7 days.
We’d like to ask you a few questions about your pain and how it is affecting your life. Please describe the location(s) of any pain you have had in the past 7 days.
What type of HEAD pain have you had in the last 7 days?
What type of NECK pain have you had in the last 7 days?
What type of SHOULDERS pain have you had in the last 7 days?
What type of ARMS pain have you had in the last 7 days?
What type of UPPER BACK pain have you had in the last 7 days?
What type of LOWER BACK pain have you had in the last 7 days?
What type of HANDS pain have you had in the last 7 days?
What type of ABDOMEN pain have you had in the last 7 days?
What type of PELVIS pain have you had in the last 7 days?
What type of HIPS pain have you had in the last 7 days?
What type of UPPER LEGS pain have you had in the last 7 days?
What type of KNEES pain have you had in the last 7 days?
What type of LOWER LEGS pain have you had in the last 7 days?
What type of FEET pain have you had in the last 7 days?
What type of EVERYWHERE pain have you had in the last 7 days?
What OTHER pain have you had in the last 7 days? Please describe
Thinking about your overall pain, in the past 7 days, please respond to the questions below:
How intense was your pain at its worse in the past 7 days
How intense was your average pain in the past 7 days
How much did pain interfere with your day to day activities in past 7 days
How much did pain interfere with your day to day activities?
How much did pain interfere with work around the home in past 7 days
How much did pain interfere with your work around the home?
How much did pain interfere with your ability to participate in social activities in past 7 days
How much did pain interfere with your ability to participate in social activities?
How much did pain interfere with your household chores in past 7 days
How much did pain interfere with your household chores?
How much did pain interfere with the things you usually do for fun in past 7 days
How much did pain interfere with the things you usually do for fun?
How much did pain interfere with your enjoyment of social activities in past 7 days
How much did pain interfere with your enjoyment of social activities?
How much did pain interfere with your enjoyment of life in past 7 days
How much did pain interfere with your enjoyment of life?
How much did pain interfere with your family life in past 7 days
How much did pain interfere with your family life?
We’d like to know more about how you manage your pain and what has worked for you. When answering these questions, please focus on pain related to what brings you in for your upcoming medical visit. These treatments are organized into sections by type: Basic therapies Mind-body therapies New therapies Non-prescription medicines Prescription medicines
What have you tried in the past 6 months to help you with your pain? Select all answers that apply. We also want to know if it worked for you.
How often have Exercises at home (such as those assigned by a therapist) or outside (such as walking, jogging, swimming) you have tried in the past 6 months helped you with your pain?
Exercises at home (such as those assigned by a therapist) or outside (such as walking, jogging, swimming)
How often have Sleep positioners or devices (such as additional pillows, padding, etc.) you have tried in the past 6 months helped you with your pain?
Sleep positioners or devices (such as additional pillows, padding, etc.)
How often has Stretching you have tried in the past 6 months helped you with your pain?
How often has Weight loss or changes in your diet you have tried in the past 6 months helped you with your pain?
How often has Setting and reaching activity goals you have tried in the past 6 months helped you with your pain?
How often has Ice or heat therapy you have tried in the past 6 months helped you with your pain?
How often has Physical therapy you have tried in the past 6 months helped you with your pain?
How often has Acupuncture you have tried in the past 6 months helped you with your pain?
How often has Chiropractic treatment you have tried in the past 6 months helped you with your pain?
How often have Other strategies or methods you have tried in the last 6 months helped with your pain? Please describe
Have you used any of the following items you can buy without a prescription from your doctor to help with your pain in the last 6 months (select all that apply)?
How often have Pain relievers (such as Advil, Aleve, Aspirin, Ibuprofen, Motrin, Tylenol) you can buy without a prescription from your doctor that you have used in the last 6 months helped with your pain?
Pain relievers (such as Advil, Aleve, Aspirin, Ibuprofen, Motrin, Tylenol)
How often have Herbal or nutritional pain relievers (such as ginseng or kava kava) that you have used in the last 6 months helped with your pain?
Herbal or nutritional pain relievers (such as ginseng or kava kava)
How often have Cremes, lotions, gels or patches applied to the skin (for example Bengay, Tiger Balm or BioFreeze) that you have used in the last 6 months helped with your pain?
Cremes, lotions, gels or patches applied to the skin (for example BENGAY®, TIGER BALM® or BiOFREEZE®)
Have you used any Other items you can buy without a prescription from your doctor to help with your pain in the last 6 months? Please describe
Other items you can buy without a prescription from your doctor, please describe
Have you used any of the following prescription medications to help with your pain in the last 6 months?
How often have prescription Opioid medications (such as hydrocodone, oxycodone, codeine, morphine and fentanyl) helped with your pain in the last 6 months?
Opioid medications (such as hydrocodone, oxycodone, codeine, morphine and fentanyl)
How often have prescription Cortisone injections (a shot to relieve inflammation) helped with your pain in the last 6 months?
Procedure or Injection (such as a shot to relieve inflammation)
How often have prescription Non-opioid medications as prescribed by a doctor (such as Celebrex, Cymbalta) helped with your pain in the last 6 months?
Non-opioid medications as prescribed by a doctor (such as Celebrex or Cymbalta)
How often has Medical marijuana helped with your pain in the last 6 months?
Have you used any Other prescription medications to help with your pain in the last 6 months?: Please describe
Have you tried any of the following new therapies to help with your pain in the last 6 months (select all that apply)?
How often has Yoga helped with your pain in the last 6 months?
How often has Massage helped with your pain in the last 6 months?
How often has Meditation helped with your pain in the last 6 months?
How often has Relaxation or mindfulness-based training helped with your pain in the last 6 months?
Relaxation or mindfulness-based training
How often has Group or individual therapy for pain helped with your pain in the last 6 months?
How often has Cognitive behavioral therapy helped with your pain in the last 6 months?
How often has Acceptance and commitment therapy helped with your pain in the last 6 months?
How often has Sleep management (such as a sleep study or CPAP) helped with your pain in the last 6 months?
Sleep management (such as a sleep study or CPAP)
Have you tried any Other mind-body techniques or therapies to help with your pain in the last 6 months? Please describe
How often has Aromatherapy helped with your pain in the last 6 months?
How often have Crystals helped with your pain in the last 6 months?
How often have Essential oils helped with your pain in the last 6 months?
How often has CBD oil helped with your pain in the last 6 months?
How often has Music therapy helped with your pain in the last 6 months?
Have you tried any Other new treatments to help with your pain in the last 6 months? Please describe
We’d like to know more about you and your goals.
What are your most important activity goals? For example: I’d like to be able to walk without pain.
We’d like to know more about you and your goals. What are your most important activity goals? For example: I’d like to be able to walk without pain.
What are the biggest barriers to achieving your activity goals? For example: I have a lot of stress from work which makes my pain worse.
Did the patient view the 4 flat tires video
Below is a link to a video produced by the American Chronic Pain Association about living with chronic pain. We’d like to suggest you watch the video to help you prepare for your upcoming visit. This video can help you prepare to ask questions that are important to you when you visit with your provider.
Did the patient access the US Chronic Pain website
The website linked below provides some information from the U.S. Pain Foundation about the causes and diagnosis of pain in general, treatment options and self management and well-being when living with pain. This information can help you prepare to ask questions that are important to you when you visit with your provider.
Please indicate your level of agreement with the following statement:
Please indicate your level of agreement with the following statement: Using the MyPAIN tool has helped me begin preparing for a conversation with my provider about managing my pain.
Using the MyPAIN tool has helped me begin preparing for a conversation with my provider about managing my pain.
Do you have any other feedback or thoughts to share on your use of MyPAIN?