9 Pain Assessment Ages 13-17

Attachment 9

Pain Assessment - Ages 13-17

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Name of test: Pain Assessment Ages 13-17
Time burden estimate: 3 minutes1
On the next screens, we will ask you questions about pain. Answer as well as you can and 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 earlier question, then choose a different
answer.
Click on the CONTINUE button when you are ready to begin.
ID

Context/Stem

PSSR13-17-01

How would you rate your pain right now?

PSSR13-17-02

In the past 7 days, how would you rate
your pain on average?

PSSR13-17-03

In the past 7 days, how intense was your
lowest level of pain?

Responses
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst imaginable pain
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst imaginable pain
Had no pain
Mild
Moderate
Severe
Very severe

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

Context/Stem

PSSR13-17-04

In the past 7 days, how intense was your
pain at its worst?

PSSR13-17-05

In the past 7 days, how often did your pain
feel intolerable?

PSSR13-17-06

In the past 7 days, I felt angry when I had
pain.

PSSR13-17-07

In the past 7 days, I had trouble doing
schoolwork when I had pain.

PSSR13-17-08

In the past 7 days, I had trouble sleeping
when I had pain.

PSSR13-17-09

In the past 7 days, it was hard for me to
pay attention when I had pain.

PSSR13-17-10

In the past 7 days, it was hard for me to
run when I had pain.

PSSR13-17-11

In the past 7 days, it was hard for me to
walk one block when I had pain.

PSSR13-17-12

In the past 7 days, it was hard to have fun
when I had pain.

Responses
Had no pain
Mild
Moderate
Severe
Very severe
Had no pain
Never
Rarely
Sometimes
Often
Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always

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

Context/Stem

PSSR13-17-13

In the past 7 days, it was hard to stay
standing when I had pain.

PSSR13-17-14

In the past 7 days, how much did pain
interfere with your day to day activities?

PSSR13-17-15

In the past 7 days, how much did pain
interfere with work around the home?

PSSR13-17-16

In the past 7 days, how much did pain
interfere with your ability to participate in
social activities?

PSSR13-17-17

In the past 7 days, how much did pain
interfere with your household chores?

PSSR13-17-18

In the past 7 days, how much did pain
interfere with the things you usually do for
fun?

PSSR13-17-19

In the past 7 days, how much did pain
interfere with your enjoyment of social
activities?

Responses
Never
Almost Never
Sometimes
Often
Almost Always
Not at all
A little bit
Somewhat
Quite a bit
Very much
Not at all
A little bit
Somewhat
Quite a bit
Very much
Not at all
A little bit
Somewhat
Quite a bit
Very much
Not at all
A little bit
Somewhat
Quite a bit
Very much
Not at all
A little bit
Somewhat
Quite a bit
Very much
Not at all
A little bit
Somewhat
Quite a bit
Very much