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4-5
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8-10
Do you feel like you
can tolerate your
pain?
Do you believe your
pain interferes with
basic needs? For
example going to the
bathroom, getting
dressed or brushing
your hair.
Do you feel that your
pain is so unbearable
that you may pass
out?
Do you feel like you
need me to call 911?
Does it interfere with
any tasks?
Do you feel the pain
interferes with your
concentration? For
example if you got
behind a wheel of a
car you could still
remember how to
drive or is it difficult
to do simple math?
Do you feel that you
pain is so bad that
you can’t think of
anything else? For
example, talking and
listening are difficult
Does your pain
interfere with your
ability to sleep?
Does your pain cause
you to frequently cry?