7 Pain Assessment Ages 3-7

Attachment 7

Pain Assessment Proxy - Ages 3-7

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

Name of test: Pain Assessment - Proxy Ages 3-7
Estimated time burden: 3 minutes
PSP5-7-00
On the next screens, you will see questions about your child's pain. Read each question
carefully and answer as best you can. After you make your choice, the computer will
automatically go on to the next question. If you want to change your answer, click on the
GO BACK button to return to the previous question and then choose a different answer.
Click on the CONTINUE button when you are ready to begin.

ID
PSP5-7-021

Context/Stem
In the past 7 days, how would you rate your child's pain
on average?

Responses
I don't know
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst
imaginable pain

PSP5-7-03

In the past 7 days, my child was angry when he or she had I don't know
pain.
Never
Almost Never
Sometimes
Often
Almost Always

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

ID
PSP5-7-04

Context/Stem
Responses
In the past 7 days, my child had trouble doing schoolwork I don't know
because of pain.
Not applicable
Never
Almost Never
Sometimes
Often
Almost Always

PSP5-7-05

In the past 7 days, my child had trouble sleeping because
of pain.

I don't know
Never
Almost Never
Sometimes
Often
Almost Always

PSP5-7-06

In the past 7 days, it was hard for my child to pay
attention because of pain.

I don't know
Never
Almost Never
Sometimes
Often
Almost Always

PSP5-7-07

In the past 7 days, it was hard for my child to run because
of pain.

I don't know
Never
Almost Never
Sometimes
Often
Almost Always

PSP5-7-08

In the past 7 days, it was hard for my child to walk one
block because of pain.

I don't know
Not applicable
Never
Almost Never
Sometimes
Often
Almost Always

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

ID
PSP5-7-09

Context/Stem
In the past 7 days, it was hard for my child to have fun
because of pain.

Responses
I don't know
Never
Almost Never
Sometimes
Often
Almost Always

PSP5-7-10

In the past 7 days, it was hard for my child to stay
standing because of pain.

I don't know
Never
Almost Never
Sometimes
Often
Almost Always