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CHRONIC PAIN RISK FACTORS QUESTIONNAIRE


The following questionnaire will help you identify the relative contribution of different physical, environmental and psychological stressors and risk-factors to your pain. This questionnaire is based on known risk factors for chronic pain. Read each statement carefully and place a tick in the box to indicate whether that statement is ‘True' for you or false (‘not true'). If it is not possible to give a strong yes or no response, answer by selecting sometimes.

Try and answer in terms of how you really feel rather than what you think is the right thing to say.

Note: Part one looks at your childhood experiences.

Part two looks at your life and your feelings and reactions now.
‘Note; This questionnaire is designed to assess the contribution that stress and psychological factors may be making to your pain. The questionnaire is not designed to assess the causal factors underlying mechanical pain.'
To answer just click the radio button which is most true for you., if you make a mistake just click the radio button you intended to indicate.
Give yourself two(2) points for every ‘true’ response and one(1) point for every ‘sometimes’ response.

Part One: When I was young:
Yes/True
Sometimes
No/False
1.    I did not have anyone to talk to or tell my problems to.
2.    I could not show my feelings.
3.    Nobody listened to me.
4.    My parents fought a lot.
5.    We moved around a lot.
6.    I did not know one or both of my real parents.
7.    I was not raised by my real parents.
8.   One of my parents abused drugs or alcohol.
9.   One of my parents had a mental illness.
10. One of my parents committed suicide.  
11. One of my parents went to jail.
12.  I often felt unsafe.
13.  I was criticised a lot.
14.  I was hurt or punished physically a lot.
15.  I was sexually abused.
ACE SCORE
Part Two: Now
 
Yes/True
Sometimes
No/False
16. I have recently lost my job
17. I have recently gone through a stressful marital break-up
18. I have recently lost someone I loved
19. There are things going on around me over which I feel I have no control
20. I have a lot of health problems
PS SCORE      
21. I often don’t know what I’m feeling
22. I have feelings I can’t quite identify
23. I prefer not to talk about my feelings
24. I’m often confused about what emotion I’m feeling
25. I don’t know what’s going on inside me
AI SCORE      
26. Sometimes I have disturbing memories or dreams about the past
27. Sometimes I find myself suddenly acting or feeling as if a past stressful event were happening again
28. I often feel distant or cut-off from people
29. I often feel “super alert” or watchful or on-guard
30. I avoid certain activities or situations that they remind me of stressful experiences from the past.
TS SCORE      
31. I often feel that I have nothing to look forward to
32. I often feel worthless as a person
33. I often feel that life is meaningless
34. I find it difficult to feel positive
35. I find it hard to feel motivated about doing things
D SCORE      
TOTAL SCORE      

If you wish you can print this page with all your responses, complete the table then refer to the links for results. When printing ensure that you print all frames.
Scoring:
Give yourself two(2) points for every ‘true’ response and one(1) point for every ‘sometimes’ response.

TOTAL  
ACE  
PS  
AI  
TS  
D  

 

 

 

 

Results can be determined by clicking the appropriate link below.

If total score was less than 6
If total score was 6 or more
If ACE score is 4 or more
If the PS score is more than 2 and the ACE score is over 4
If the PS score is more than 2 and the ACE score is under 4
 If AI score is more than 2, regardless of other responses
If AI score is 2 and the ACE score is over 4 or the PS and/or TS score is over 2
If TS score was more than 3
If D score is more than 3, ACE is 4 or more and PS and/or TS is over 2
If ACE score is under 4 and PS & TS scores are under 2

All rights and copyright of this questionnaire belong to ©2004 Mark Grant