Pain Measurement form
Required
Required
Required
No Pain
Worst Imaginable Pain
Required
No Pain
Worst Imaginable Pain
Required
No Pain
Worst Imaginable Pain
Required
No Pain
Worst Imaginable Pain
Required
No Relief
Complete Relief
Required
How, in the last week, has the pain interfered with the following:
No Interference
Completely Interferes
Required
No Interference
Completely Interferes
Required
No Interference
Completely Interferes
Required
No Interference
Completely Interferes
Required
No Interference
Completely Interferes
Required
No Interference
Completely Interferes
Required
No Interference
Completely Interferes
Required
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