| Demographic Data |
surveyID |
Participant ID |
| Demographic Data |
date.finish |
Survey Timestamp |
| Demographic Data |
ID |
Study ID |
| Demographic Data |
visit |
Visit number |
| Demographic Data |
date.start |
Date and time |
| Demographic Data |
age |
What is your current age, in years? |
| Demographic Data |
sex |
What is your sex? |
| Demographic Data |
ethnicity |
What is your ethnicity? |
| Demographic Data |
race |
What is your race? |
| Demographic Data |
ed |
What is the highest grade you completed? |
| Demographic Data |
empoy |
Please check the one item that best describes your current employment status. |
| Demographic Data |
salary |
What is the total annual income of your household? |
| Demographic Data |
married |
What is your current partnership status? |
| Demographic Data |
house.size |
Including yourself, how many people live in your house? |
| Demographic Data |
tx |
What is your pain diagnosis? |
| Demographic Data |
sx.length |
For how long have you experienced pain symptoms? |
| Demographic Data |
tx.length |
For how many years have you been treated for your pain? |
| SF36 |
SF_36.1 |
1. In general, would you say your health is: |
| SF36 |
SF_36.2 |
2. Compared to one year ago, how would you rate your health in general now? |
| SF36 |
SF_36.3 |
a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports |
| SF36 |
SF_36.4 |
b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf |
| SF36 |
SF_36.5 |
c. Lifting or carrying groceries |
| SF36 |
SF_36.6 |
d. Climbing several flights of stairs |
| SF36 |
SF_36.7 |
e. Climbing one flight of stairs |
| SF36 |
SF_36.8 |
f. Bending, kneeling, or stooping |
| SF36 |
SF_36.9 |
g. Walking more than a mile |
| SF36 |
SF_36.10 |
h. Walking several hundred yards |
| SF36 |
SF_36.11 |
i. Walking one hundred yards |
| SF36 |
SF_36.12 |
J. Bathing or dressing yourself |
| SF36 |
SF_36.13 |
a. Cut down on the amount of time you spent on work or other activities |
| SF36 |
SF_36.14 |
b. Accomplished less than you would like |
| SF36 |
SF_36.15 |
c. Were limited in the kind of work or other activities |
| SF36 |
SF_36.16 |
d. Had difficulty performing the work or other activities (for example, it took extra effort) |
| SF36 |
SF_36.17 |
a. Cut down on the amount of time you spent on work or other activities |
| SF36 |
SF_36.18 |
b. Accomplished less than you would like |
| SF36 |
SF_36.19 |
c. Did work or other activities less carefully than usual |
| SF36 |
SF_36.20 |
6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? |
| SF36 |
SF_36.21 |
7. How much bodily pain have you had during the past 4 weeks? |
| SF36 |
SF_36.22 |
8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? |
| SF36 |
SF_36.23 |
a. Did you feel full of life? |
| SF36 |
SF_36.24 |
b. Have you been very nervous? |
| SF36 |
SF_36.25 |
c. Have you felt so down in the dumps that nothing could cheer you up? |
| SF36 |
SF_36.26 |
d. Have you felt calm and peaceful? |
| SF36 |
SF_36.27 |
e. Did you have a lot of energy? |
| SF36 |
SF_36.28 |
f. Have you felt downhearted and depressed? |
| SF36 |
SF_36.29 |
g. Did you feel worn out? |
| SF36 |
SF_36.30 |
h. Have you been happy? |
| SF36 |
SF_36.31 |
i. Did you feel tired? |
| SF36 |
SF_36.32 |
10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? |
| SF36 |
SF_36.33 |
a. I seem to get sick a little easier than other people |
| SF36 |
SF_36.34 |
b. I am as healthy as anybody I know |
| SF36 |
SF_36.35 |
c. I expect my health to get worse |
| SF36 |
SF_36.36 |
d. My health is excellent |
| SF-MPQ |
MPQ.1 |
Throbbing pain |
| SF-MPQ |
MPQ.2 |
Shooting pain |
| SF-MPQ |
MPQ.3 |
Stabbing Pain |
| SF-MPQ |
MPQ.4 |
Sharp pain |
| SF-MPQ |
MPQ.5 |
Gnawing pain |
| SF-MPQ |
MPQ.6 |
Cramping pain |
| SF-MPQ |
MPQ.7 |
Hot-burning pain |
| SF-MPQ |
MPQ.8 |
Aching pain |
| SF-MPQ |
MPQ.9 |
Heavy pain |
| SF-MPQ |
MPQ.10 |
Tender |
| SF-MPQ |
MPQ.11 |
Splitting pain |
| SF-MPQ |
MPQ.12 |
Tiring-exhausting |
| SF-MPQ |
MPQ.13 |
Sickening |
| SF-MPQ |
MPQ.14 |
Fearful |
| SF-MPQ |
MPQ.15 |
Punishing-cruel |
| SF-MPQ |
MPQ.16 |
Electric-shock pain |
| SF-MPQ |
MPQ.17 |
Cold-freezing pain |
| SF-MPQ |
MPQ.18 |
Piercing |
| SF-MPQ |
MPQ.19 |
Pain caused by light touch |
| SF-MPQ |
MPQ.20 |
Itching |
| SF-MPQ |
MPQ.21 |
Tingling or ‘pins and needles’ |
| SF-MPQ |
MPQ.22 |
Numbness |
| ACE: See Violence |
ACE.1.1 |
Before you were 18, did you witness any violence between your parents, guardians or caretakers? For example, screaming, swearing, hitting, beating, kicking, biting, slapping, or shoving; or using a knife, gun or other object to harm the other person? |
| ACE: See Violence |
ACE.1.2 |
How severe was this parental violence? |
| ACE: See Violence |
ACE.1.3 |
How frequently did this violence occur? |
| ACE: See Violence |
ACE.1.4 |
At approximately what age do you first remember witnessing this violence? |
| ACE: See Violence |
ACE.1.5 |
Looking back now, how much of an impact did witnessing this violence have on you before you were 18? |
| ACE: See Violence |
ACE.1.6 |
How would you describe the impact of witnessing this violence on your life before you were 18? |
| ACE: See Violence |
ACE.1.7 |
How much of an impact does witnessing this violence continue to have on your life now? |
| ACE: See Violence |
ACE.1.8 |
How would you describe the impact of witnessing this violence on your life now? |
| ACE: Physically Harmed |
ACE.2.1 |
Before you were 18, were you physically harmed by a parent, guardian or caregiver? For example, were you severely spanked, pushed, grabbed, shoved, slapped, had something thrown at you, or hit so hard that you had marks or injuries? |
| ACE: Physically Harmed |
ACE.2.2 |
How severe was the physical harm? |
| ACE: Physically Harmed |
ACE.2.3 |
How frequently did this physical harm occur? |
| ACE: Physically Harmed |
ACE.2.4 |
At approximately what age do you first remember experiencing this physical harm? |
| ACE: Physically Harmed |
ACE.2.5 |
Looking back now, how much of an impact did this physical harm have on you before you were 18? |
| ACE: Physically Harmed |
ACE.2.6 |
How would you describe the impact of this physical harm on your life before you were 18? |
| ACE: Physically Harmed |
ACE.2.7 |
How much of an impact does this physical harm continue to have on your life now? |
| ACE: Physically Harmed |
ACE.2.8 |
How would you describe the impact of this physical harm on your life now? |
| ACE: Sexual Abuse |
ACE.3.1 |
Before you were 18, did you have any unwanted sexual experiences? For example, did anyone touch you in a sexual way, or make you touch them; or make you do sexual things or watch sexual things; or actually have oral, anal, or vaginal intercourse with you when you did not want to? |
| ACE: Sexual Abuse |
ACE.3.2 |
How severe were these unwanted sexual experience(s)? |
| ACE: Sexual Abuse |
ACE.3.3 |
How frequently did these unwanted sexual experience(s) occur? |
| ACE: Sexual Abuse |
ACE.3.4 |
At approximately what age do you first remember having unwanted sexual experience(s)? |
| ACE: Sexual Abuse |
ACE.3.5 |
Looking back now, how much of an impact did these unwanted sexual experience(s) have on you while you were growing up? |
| ACE: Sexual Abuse |
ACE.3.6 |
How would you describe the impact of these unwanted sexual experience(s) have on your life while you were growing up? |
| ACE: Sexual Abuse |
ACE.3.7 |
How much of an impact do these unwanted sexual experience(s) continue to have on your life now? |
| ACE: Sexual Abuse |
ACE.3.8 |
How would you describe the impact of these unwanted sexual experience(s) on your life now? |
| ACE: Verbal/Psychlogical Abuse |
ACE.4.1 |
Before you were 18, did you experience any emotional/psychological mistreatment? For example did your parents or guardians swear at you, insult you or put you down, ridicule you, terrorize you (lock you in a closet), deny you food or water, or make you feel ashamed or guilty? |
| ACE: Verbal/Psychlogical Abuse |
ACE.4.2 |
How severe was the emotional/psychological mistreatment? |
| ACE: Verbal/Psychlogical Abuse |
ACE.4.3 |
How frequently did the emotional/psychological mistreatment occur? |
| ACE: Verbal/Psychlogical Abuse |
ACE.4.4 |
At approximately what age do you first remember experiencing emotional/psychological mistreatment? |
| ACE: Verbal/Psychlogical Abuse |
ACE.4.5 |
Looking back now, how much of an impact did this emotional/psychological mistreatment have on you before you were 18? |
| ACE: Verbal/Psychlogical Abuse |
ACE.4.6 |
How would you describe the impact of this emotional/psychological mistreatment on your life before you were 18? |
| ACE: Verbal/Psychlogical Abuse |
ACE.4.7 |
How much of an impact does this emotional/psychological mistreatment continue to have on your life now? |
| ACE: Verbal/Psychlogical Abuse |
ACE.4.8 |
How would you describe the impact of this emotional/psychological mistreatment on your life now? |
| ACE: Emotional Neglect |
ACE.5.1 |
Before you were 18, were you emotionally neglected? For example, did you parents, caregivers or guardians treat you as if they did not care about you, forgot about you or left you alone for long periods of time? |
| ACE: Emotional Neglect |
ACE.5.2 |
How severe was the emotional neglect? |
| ACE: Emotional Neglect |
ACE.5.3 |
How frequently did the emotional neglect occur? |
| ACE: Emotional Neglect |
ACE.5.4 |
At approximately what age do you first remember experiencing this emotional neglect? |
| ACE: Emotional Neglect |
ACE.5.5 |
Looking back now, how much of an impact did this emotional neglect have on you before you were 18? |
| ACE: Emotional Neglect |
ACE.5.6 |
How would you describe the impact of this emotional neglect on your life before you were 18? |
| ACE: Emotional Neglect |
ACE.5.7 |
How much of an impact does this emotional neglect continue to have on your life now? |
| ACE: Emotional Neglect |
ACE.5.8 |
How would you describe the impact of this emotional neglect on your life now? |
| ACE: Physical Neglect |
ACE.6.1 |
Before you were 18, were you physically neglected? For example, did you parents, caregivers or guardians fail to provide you with basic needs like food, water, adequate clothing or shelter? |
| ACE: Physical Neglect |
ACE.6.2 |
How severe was the physical neglect? |
| ACE: Physical Neglect |
ACE.6.3 |
How frequently did the physical neglect occur? |
| ACE: Physical Neglect |
ACE.6.4 |
At approximately what age do you first remember experiencing this physical neglect? |
| ACE: Physical Neglect |
ACE.6.5 |
Looking back now, how much of an impact did this physical neglect have on you before you were 18? |
| ACE: Physical Neglect |
ACE.6.6 |
How would you describe the impact of this physical neglect on your life before you were 18? |
| ACE: Physical Neglect |
ACE.6.7 |
How much of an impact does this physical neglect continue to have on your life now? |
| ACE: Physical Neglect |
ACE.6.8 |
How would you describe the impact of this physical neglect on your life now? |
| CSQ |
CSQ.1 |
When I feel pain I try to feel distant from the pain, almost as if the pain was in somebody else’s body. |
| CSQ |
CSQ.2 |
When I feel pain I try to think of something pleasant. |
| CSQ |
CSQ.3 |
When I feel pain it’s terrible and I feel it’s never going to get any better. |
| CSQ |
CSQ.4 |
When I feel pain I tell myself to be brave and carry on despite the pain. |
| CSQ |
CSQ.5 |
When I feel pain I tell myself that I can overcome the pain. |
| CSQ |
CSQ.6 |
When I feel pain it’s awful and I feel that it overwhelms me. |
| CSQ |
CSQ.7 |
When I feel pain I feel my life isn’t worth living. |
| CSQ |
CSQ.8 |
When I feel pain I pray to God it won’t last long. |
| CSQ |
CSQ.9 |
When I feel pain I try not to think of it as my body, but rather as something separate from me. |
| CSQ |
CSQ.10 |
When I feel pain I don’t think about the pain. |
| CSQ |
CSQ.11 |
When I feel pain I tell myself I can’t let the pain stand in the way of what I have to do. |
| CSQ |
CSQ.12 |
When I feel pain I don’t pay any attention to it. |
| CSQ |
CSQ.13 |
When I feel pain I pretend it’s not there. |
| CSQ |
CSQ.14 |
When I feel pain I worry all the time about whether it will end. |
| CSQ |
CSQ.15 |
When I feel pain I replay in my mind pleasant experiences in the past. |
| CSQ |
CSQ.16 |
When I feel pain I think of people I enjoy doing things with. |
| CSQ |
CSQ.17 |
When I feel pain I pray for the pain to stop. |
| CSQ |
CSQ.18 |
When I feel pain I imagine that the pain is outside of my body. |
| CSQ |
CSQ.19 |
When I feel pain I just go on as if nothing happened. |
| CSQ |
CSQ.20 |
When I feel pain although it hurts, I just keep going. |
| CSQ |
CSQ.21 |
When I feel pain I feel I can’t stand it anymore. |
| CSQ |
CSQ.22 |
When I feel pain I ignore it. |
| CSQ |
CSQ.23 |
When I feel pain I rely on my faith in God. |
| CSQ |
CSQ.24 |
When I feel pain I feel like I can’t go on. |
| CSQ |
CSQ.25 |
When I feel pain I think of things I enjoy doing. |
| CSQ |
CSQ.26 |
When I feel pain I do something I enjoy, such as watching TV or listening to music. |
| CSQ |
CSQ.27 |
When I feel pain I pretend it’s not a part of me. |
| HSCL10 |
HSCL.1 |
Suddenly scared for no reason |
| HSCL10 |
HSCL.2 |
Feeling fearful |
| HSCL10 |
HSCL.3 |
Faintness, dizziness or weakness |
| HSCL10 |
HSCL.4 |
Nervousness or shakiness inside |
| HSCL10 |
HSCL.5 |
Heart pounding hard or racing |
| HSCL10 |
HSCL.6 |
Trembling |
| HSCL10 |
HSCL.7 |
Feeling tense or keyed up |
| HSCL10 |
HSCL.8 |
Headaches |
| HSCL10 |
HSCL.9 |
Spells of terror or panic |
| HSCL10 |
HSCL.10 |
Feeling restless, can’t sit still |
| BPI |
BPI.1 |
Throughout our lives, most of us had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these everyday kinds of pain today? |
| BPI |
BPI.2 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=A) |
| BPI |
BPI.3 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=B) |
| BPI |
BPI.4 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=C) |
| BPI |
BPI.5 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=D) |
| BPI |
BPI.6 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=E) |
| BPI |
BPI.7 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=F) |
| BPI |
BPI.8 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=G) |
| BPI |
BPI.9 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=H) |
| BPI |
BPI.10 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=I) |
| BPI |
BPI.11 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=J) |
| BPI |
BPI.12 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=K) |
| BPI |
BPI.13 |
On the diagram above, select the areas where you feel pain. Check all that apply. (choice=L) |
| BPI |
BPI.14 |
From the same diagram above, select the area that hurts the most. |
| BPI |
BPI.15 |
Please rate your pain by indicating the number that best describes your pain at its WORST in the last 24 hours. |
| BPI |
BPI.16 |
Please rate your pain by indicating the one number that best describes your pain at its LEAST in the last 24 hours. |
| BPI |
BPI.17 |
Please rate your pain by indicating the one number that best describes your pain on the AVERAGE. |
| BPI |
BPI.18 |
Please rate your pain by indicating the one number that tells how much pain you have RIGHT NOW. |
| BPI |
BPI.19 |
What treatments or medications are you receiving for your pain? |
| BPI |
BPI.20 |
In the last 24 hours, how much relief have pain treatments or medications provided? Please indicated the one percentage that most shows how much RELIEF you have received. |
| BPI |
BPI.21 |
A. General Activity |
| BPI |
BPI.22 |
B. Mood |
| BPI |
BPI.23 |
C. Walking Ability |
| BPI |
BPI.24 |
D. Normal Work (includes both work outside the home and housework) |
| BPI |
BPI.25 |
E. Relations with other people |
| BPI |
BPI.26 |
F. Sleep |
| BPI |
BPI.27 |
G. Enjoyment of life |
|
Complete |
Complete? |