- Look at the Pain Rating Scale, and rate your current pain from "no pain" to "worst pain imaginable. (Note: Bay’s Pain Management Center uses a 0-10 pain rating scale.)
- Check your tolerance for pain:
___ I can tolerate almost any pain (except for the pain I’m experiencing now)
___ I have a fairly high threshold for pain.
___ I have a moderate threshold for pain.
___ I have a low threshold for pain I (I don’t want to feel a thing!)
- When do you experience pain?
___ Sitting ___ Bending (i.e., to get in a car)
___ Standing ___ Turning my body
___ Walking ___ Doing household chores
___ Lifting (anything above one pound) ___ Sleeping (can’t get comfortable)
___ Other (list activity)
- How often do you experience pain?
___ Only after strenuous activity ___ Only on rare occasions
___ Only when I move a certain way ___ Occasionally
___ Every day ___ All the time
- Where is your pain? (check all that apply):
____ Back ___ Lower back ____ Legs
____ Shoulders ___ Head ____ Abdomen
____ Neck ___ Arms ____ Other (list)
- What do you currently do for pain relief?
___ Take aspirin (No.: ) ____ Rest
___ Take Tylenol (No.: ) ____ Use ice pack
___Take ibuprofen No.: ) ____ Hot shower or bath
___ Massage ____ Other (list)