| Source | cqf.fhir.cds4cpm#current:Clinical Decision Support for Chronic Pain Management and Shared Decision-Making IG (v4.0.1) |
| resourceType | Questionnaire |
| id | mypain-questionnaire-ufl |
| canonical | http://fhir.org/guides/cqf/cds4cpm/Questionnaire/mypain-questionnaire-ufl |
| version | 0.1.0 |
| status | active |
| publisher | CQF |
| name | mypainquestionnaireufl |
| title | MyPain Questionnaire |
| date | 2023-08-14T15:26:57+00:00 |
| experimental | false |
| description | 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. Created for UFL pilot. |
| jurisdictions | uv |
| Usages | (none) |
My Pain Location: <strong>Where</strong> is the pain you would like to discuss?
Head: What does it feel like?
Neck: What does it feel like?
Shoulders: What does it feel like?
Arms: What does it feel like?
Back: What does it feel like?
Hands/Wrist: What does it feel like?
Abdomen/Pelvis: What does it feel like?
Hips: What does it feel like?
Knees: What does it feel like?
Feet/Ankles: What does it feel like?
Everywhere: What does it feel like?
Other, please describe: Other, please describe
My Pain Intensity: Over the past 7 days...
How intense was your <strong>pain at its worst</strong>?
How intense was your <strong>average pain</strong>?
What is your level of <strong>pain right now</strong>?
My Pain Interference: Over the past 7 days...
How much did pain interfere with your <strong>day to day activities</strong>?
How much did pain interfere with your <strong>work around the home</strong>?
How much did pain interfere with your <strong>ability to participate in social activities</strong>?
How much did pain interfere with your <strong>household chores</strong>?
My Pain Interference: Over the past 7 days...
How much did pain <em>interfere</em> with <strong>things you usually do for fun</strong>?
How much did pain <em>interfere</em> with your <strong>enjoyment of social activities</strong>?
How much did pain <em>interfere</em> with your <strong>enjoyment of life</strong>?
How much did pain <em>interfere</em> with your <strong>family life</strong>?
About My Treatments: What <strong>medications</strong> have you tried for pain?
<strong>Over-the-counter</strong> pain reliever (such as Advil, Aleve, Aspirin, Ibuprofen, Motrin, or Tylenol): Did it work?
<strong>Prescription nonsteroidal anti-inflammatory</strong> (such as Celebrex): Did it work?
<strong>Prescription nerve pain</strong> medication (such as Lyrica, Neurontin, or Cymbalta): Did it work?
<strong>Prescription muscle relaxant</strong> (such as Soma or Baclofen): Did it work?
<strong>Prescription opioid</strong> medication (such as Vicodin, hydrocodone, oxycodone, codeine, morphine, or tramadol): Did it work?
<strong>Other</strong>: describe other medications you've tried for pain: Other: describe other medications you've tried for pain
I haven't tried any medications for pain.: <strong>I haven't tried any medications for pain.</strong>
About My Treatments: What <strong>specialists</strong> have you seen for pain?
<strong>Chiropractor</strong>: Did it work?
<strong>Physical therapist</strong>: Did it work?
<strong>Pain management specialist</strong>: Did it work?
<strong>Orthopedist</strong>: Did it work?
<strong>Psychologist</strong> or <strong>counselor</strong> (such as for group or individual therapy, acceptance & commitment therapy, cognitive behavior therapy): Did it work?
<strong>Integrative medicine specialist</strong>: Did it work?
<strong>Other</strong>: describe other specialists you have seen for pain (such as neurologist, spine doctor rheumatologist, or physiatrist): <strong>Other</strong>: describe other specialists you have seen for pain (such as neurologist, spine doctor rheumatologist, or physiatrist)
I haven't seen any specialists for pain: <strong>I haven't seen any specialists for pain.</strong>
About My Treatments: What <strong>procedures</strong> or <strong>physical treatments</strong> have you tried for pain?
<strong>Surgery</strong>: Did it work?
<strong>Injection</strong> (such as a shot to relieve inflammation): Did it work?
<strong>Massage</strong>: Did it work?
<strong>Dry needling</strong> or <strong>cupping</strong>: Did it work?
<strong>Acupuncture</strong>: Did it work?
<strong>Other</strong>: describe other procedures or physical treatments you've tried for pain: Other, please describe
I haven't tried any procedures or physical treatments for pain.: <strong>I haven't tried any procedures or physical treatments for pain.</strong>
About My Treatments: What <strong>topical treatments</strong> or <strong>devices</strong> have you tried for pain?
<strong>Heat</strong> and/or <strong>ice</strong>: Did it work?
<strong>Topical medications</strong> (such as creams, lotions, gel, patches, Bengay, Tiger Balm, Salonpas, Biofreeze, or Lidoderm): Did it work?
<strong>TENs unit</strong> device: Did it work?
<strong>Bracing</strong>: Did it work?
<strong>Other</strong>: describe other topical treatments or devices you've tried for pain: <strong>Other</strong>: describe other topical treatments or devices you've tried for pain
I haven't tried any topical treatments or devices for pain.: <strong>I haven't tried any topical treatments or devices for pain.</strong>
About My Treatments: What <strong>lifestyle changes</strong> have you tried for pain?
<strong>Exercises</strong> or </strong>stretching</strong> (such as walking, yoga, water aerobics): Did it work?
<strong>Diet</strong> or <strong>hydration</strong> (such as an anti-inflammatory diet or drinking enough water): Did it work?
<strong>Weight loss</strong>: Did it work?
<strong>Stress reduction</strong> (such as relaxation, meditation, mindfulness, laughter): Did it work?
<strong>Posture</strong> or <strong>ergonomics</strong>: Did it work?
<strong>Other</strong>: describe other lifestyle changes you've tried for pain : <strong>Other</strong>: describe other lifestyle changes you've tried for pain
I haven't tried any lifestyle changes for pain.: <strong>I haven't tried any lifestyle changes for pain.</strong>
About My Treatments: What <strong>alternative treatments</strong> have you tried for pain?
<strong>Herbal treatments or supplements</strong> (such as ginseng or kava kava): Did it work?
<strong>Aromatherapy</strong>: Did it work?
<strong>CBD oil</strong>: Did it work?
<strong>Marijuana</strong> used for medical purposes: Did it work?
<strong>Other</strong>: describe other alternative treatments you've tried for pain: <strong>Other</strong>: describe other alternative treatments you've tried for pain
I haven't tried any alternative treatments for pain: <strong>I haven't tried any alternative treatments for pain</strong>
About My Goals: <strong>Activity Goals</strong>: what goals do you have for your daily activities?<br/><br/>Examples: <em>I want to walk my dog daily. I want to continue to play guitar with my son.</em>
About My Goals: <strong>Activity Barriers</strong>: what are the biggest barriers to achieving your daily activity goals?<br/><br/>Example: <em>I have a lot of stress from work that makes my pain worse.</em>
Produced 08 Sep 2023