Description:

USMCI 8214/Z6091: Brief Pain Inventory (Short Form) NCT01167725 Standard Therapy With or Without Surgery and Mitomycin C in Treating Patients With Advanced Limited Peritoneal Dissemination of Colon Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=665B3662-59E6-0174-E040-BB89AD431E1F

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=665B3662-59E6-0174-E040-BB89AD431E1F

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Versions (3) ▾
  1. 8/27/12
  2. 1/9/15
  3. 6/26/15
Uploaded on:

June 26, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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USMCI 8214/Z6091: Brief Pain Inventory (Short Form) NCT01167725

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  1. StudyEvent: USMCI 8214/Z6091: Brief Pain Inventory (Short Form)
    1. No Instruction available.
Header Module
Brief Pain Assessment
Throughout our lives, most of us have 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? (1.)
Please rate your pain by marking the box beside the number that best describes your pain at its WORST in the past 24 hours. (3.)
Please rate your pain by marking the box beside the number that best describes your pain at its LEAST in the past 24 hours. (4.)
Please rate your pain by marking the box beside the number that best describes your pain on the AVERAGE. (5.)
Please rate your pain by marking the box beside the number that tells how much pain you have RIGHT NOW. (6.)
In the past 24 hours, how much RELIEF have pain treatments or medications provided? (Please select the percentage that shows how much.)
Assessment of Patient Activity
General Activity (9.)
Mood (10.)
Walking ability (11.)
Normal work (includes both work outside the home and housework)
Relations with other people (13.)
Sleep (14.)
Enjoyment of life

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