ID

41756

Description

Otis-Green, S., & The City of Hope Pain/Palliative Resource Center. (2012) . The Psychosocial Pain Assessment Form (PPAF). Measurement Instrument Database for the Social Science. Retrieved 12.01.2021, from www.midss.ie. Key references: Otis-Green, S. (2006). Psychosocial Pain Assessment Form. In Dow (Ed.), Nursing Care of Women with Cancer. St. Louis, MO: Elsevier Mosby, 556-561. Otis-Green, S. (2005). Psychosocial Pain Assessment Form. In Kuebler, Davis, Moore (Eds.), Palliative Practices: An Interdisciplinary Approach. St. Louis, MO: Elsevier Mosby, 462-467. Primary use / Purpose: The Psychosocial Pain Assessment Form (PPAF) is a comprehensive assessment form for measuring psychosocial pain. It does so under five domains: economic, social support, activities of daily living, emotional impact, and coping style. Additionally, an assessment of prior history is included to help clinicians focus interventions where sexual abuse or other traumatic memories are present. Background: The psychosocial model of pain is now widely accepted. Pain is no longer treated, or thought of, as a purely physiological condition, but instead, one that is the product of a myriad of both psychological and physiological factors. For this reason, there is a need for instruments which measure the full range of outcomes and causes associated with chronic pain, whether they be psychological, economic, or physiological. The Psychosocial Pain Assessment Form (PPAF) was developed to be used in this capacity. Digital Object Identifier (DOI): http://dx.doi.org/10.13072/midss.344

Link

www.midss.ie

Keywords

Versions (1)
  1. 1/13/21 1/13/21 -
Copyright Holder

Otis-Green, S., & The City of Hope Pain/Palliative Resource Center

Uploaded on

January 13, 2021

DOI

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License

Creative Commons BY 4.0
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Measurement Instrument Database for the Social Science (MIDSS)

English

The Psychosocial Pain Assessment Form (PPAF)

1 forms  
Psychosocial Pain Assessment Form
Description

Psychosocial Pain Assessment Form

Alias
UMLS CUI-1
C0030193
UMLS CUI-2
C1455743
Patient
Description

Patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Age
Description

Age

Data type

text

Alias
UMLS CUI [1]
C0001779
Date
Description

Date in time

Data type

date

Alias
UMLS CUI [1]
C0011008
Med. Record #
Description

Medical record number

Data type

integer

Alias
UMLS CUI [1]
C1301894
Significant Other
Description

Partner in relationship

Data type

text

Alias
UMLS CUI [1]
C0682323
Diagnosis
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Primary Physician
Description

Primary physician

Data type

text

Alias
UMLS CUI [1]
C1508823
Pain Syndrome
Description

Pain Disorder

Data type

text

Alias
UMLS CUI [1]
C0391976
Duration of Pain
Description

Pain, Duration

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0449238
Assessed by
Description

Pain, Psychosocial assessment, Health professional

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C1704312
Build
Description

Physique type

Data type

text

Alias
UMLS CUI [1]
C0424611
Attire
Description

Clothing

Data type

text

Alias
UMLS CUI [1]
C0009072
Eye Contact
Description

eye contact

Data type

text

Alias
UMLS CUI [1]
C0870532
Attention
Description

Attention

Data type

text

Alias
UMLS CUI [1]
C0004268
Manner
Description

Demeanor

Data type

text

Alias
UMLS CUI [1]
C0683298
Verbal Expression
Description

Verbal communication

Data type

text

Alias
UMLS CUI [1]
C0150820
Reasoning Ability
Description

Ability to use verbal reasoning

Data type

text

Alias
UMLS CUI [1]
C0582572
Overall Perspective
Description

Overall Response

Data type

text

Alias
UMLS CUI [1]
C3272903
Impressions
Description

Pain, Psychosocial assessment, Impressions

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C1998467
Interventions
Description

Pain, Psychosocial assessment, Interventional procedure

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0184661
Recommendations
Description

Pain, Psychosocial assessment, Recommendations

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0034866
Rating (0-10; 0 = no concern, 10 = greatest concern)
Description

Rating (0-10; 0 = no concern, 10 = greatest concern)

Alias
UMLS CUI-1
C0030193
UMLS CUI-2
C1455743
UMLS CUI-3
C0681889
Economic - Interviewer
Description

Pain, Psychosocial assessment, Economic

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0013557
Economic - Patient
Description

Pain, Psychosocial assessment, Economic

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0013557
Economic - Significant Other
Description

Pain, Psychosocial assessment, Economic

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0013557
Social Support - Interviewer
Description

Pain, Psychosocial assessment, Social support

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0037438
Social Support - Patient
Description

Pain, Psychosocial assessment, Social support

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0037438
Social Support - Significant Other
Description

Pain, Psychosocial assessment, Social support

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0037438
Activities of daily living - Interviewer
Description

Pain, Psychosocial assessment, Activities of Daily Living

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0001288
Activities of daily living - Patient
Description

Pain, Psychosocial assessment, Activities of Daily Living

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0001288
Activities of daily living - Significant Other
Description

Pain, Psychosocial assessment, Activities of Daily Living

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0001288
Emotional - Interviewer
Description

Pain, Psychosocial assessment, Emotional Well-being

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C2984554
Emotional - Patient
Description

Pain, Psychosocial assessment, Emotional Well-being

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C2984554
Emotional - Significant Other
Description

Pain, Psychosocial assessment, Emotional Well-being

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C2984554
Coping - Interviewer
Description

Pain, Psychosocial assessment, Coping Behavior

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0009967
Coping - Patient
Description

Pain, Psychosocial assessment, Coping Behavior

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0009967
Coping - Significant Other
Description

Pain, Psychosocial assessment, Coping Behavior

Data type

integer

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0009967
Economic
Description

Economic

Alias
UMLS CUI-1
C0030193
UMLS CUI-2
C1455743
UMLS CUI-3
C0013557
How are you supporting yourself financially?
Description

Financial Support

Data type

text

Alias
UMLS CUI [1]
C0016118
Some people we see are concerned about meeting their economic needs. Which of these are worrisome to you?
Description

Economic, Concern

Data type

text

Alias
UMLS CUI [1,1]
C0013557
UMLS CUI [1,2]
C2699424
How has your economic situation changed?
Description

Economic Status, Changed status

Data type

text

Alias
UMLS CUI [1,1]
C0337781
UMLS CUI [1,2]
C0443172
Describe
Description

Economic Status, Changed status

Data type

text

Alias
UMLS CUI [1,1]
C0337781
UMLS CUI [1,2]
C0443172
How upsetting have these changes been to you? Describe
Description

Economic Status, Changed status, Feeling upset

Data type

text

Alias
UMLS CUI [1,1]
C0337781
UMLS CUI [1,2]
C0443172
UMLS CUI [1,3]
C3887804
What would be different in your life if you could afford to change it? Describe
Description

Economic Status, Patient Wish

Data type

text

Alias
UMLS CUI [1,1]
C0337781
UMLS CUI [1,2]
C0443172
UMLS CUI [1,3]
C3887804
UMLS CUI [1,4]
C0747309
Please rate your overall level of concern regarding these economic issues (0-10; 0 = no concern at all; 10 = greatest concern) - Interviewer
Description

Pain, Psychosocial assessment, Economic

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0013557
Please rate your overall level of concern regarding these economic issues (0-10; 0 = no concern at all; 10 = greatest concern) - Patient
Description

Pain, Psychosocial assessment, Economic

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0013557
Please rate your overall level of concern regarding these economic issues (0-10; 0 = no concern at all; 10 = greatest concern) - Significant Other
Description

Pain, Psychosocial assessment, Economic

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0013557
Social Support
Description

Social Support

Alias
UMLS CUI-1
C0030193
UMLS CUI-2
C1455743
UMLS CUI-3
C0037438
Who do you turn to when you're uncomfortable or in pain?
Description

Pain, Social support

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0037438
Name
Description

Pain, Social support, Name

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0037438
UMLS CUI [1,3]
C0027365
Relationship
Description

Pain, Social support, Relationships

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0037438
UMLS CUI [1,3]
C0439849
How accessible is this person to you?
Description

Pain, Social support, Accessibility

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0037438
UMLS CUI [1,3]
C0814423
How helpful is this to you?
Description

Pain, Social support, Helpful

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0037438
UMLS CUI [1,3]
C3898897
How comfortable are you sharing your feelings/fears with your loved ones? What makes this difficult for you? Describe
Description

Feelings, Sharing

Data type

text

Alias
UMLS CUI [1,1]
C1527305
UMLS CUI [1,2]
C0237876
How satisfied are you with communication with your doctor/medical team? Describe
Description

Communication, Physicians

Data type

text

Alias
UMLS CUI [1,1]
C0009452
UMLS CUI [1,2]
C0031831
Losing people who are important to us affects us deeply. Have you suffered any recent losses?
Description

Recent loss of close family member &or friend

Data type

boolean

Alias
UMLS CUI [1]
C1716700
Losing people who are important to us affects us deeply. Have you suffered any recent losses? Describe
Description

Recent loss of close family member &or friend

Data type

text

Alias
UMLS CUI [1]
C1716700
Losing people who are important to us affects us deeply. Have you suffered any recent losses? Describe
Description

Recent loss of close family member &or friend

Data type

text

Alias
UMLS CUI [1]
C1716700
Please rate your overall level of concern regarding these social support issues (0-10; 0 = no concern, 10 = greatest concern) - Interviewer
Description

Pain, Psychosocial assessment, Social support

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0600015
Please rate your overall level of concern regarding these social support issues (0-10; 0 = no concern, 10 = greatest concern) - Patient
Description

Pain, Psychosocial assessment, Social support

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0600015
Please rate your overall level of concern regarding these social support issues (0-10; 0 = no concern, 10 = greatest concern) - Significant Other
Description

Pain, Psychosocial assessment, Social support

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0600015
Activities of Daily Living
Description

Activities of Daily Living

Alias
UMLS CUI-1
C0030193
UMLS CUI-2
C1455743
UMLS CUI-3
C0001288
Often unrelieved pain affects a person's daily routine. How has your pain impacted you in these activities of daily living? 1. Affecting your sleeping patterns?
Description

Pain, Affection, Sleep behavior finding

Data type

boolean

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0474396
1. Affecting your sleeping patterns?
Description

Pain, Affection, Sleep behavior finding

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0474396
2. Affecting your eating habits?
Description

Pain, Eating habit

Data type

boolean

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1266864
2. Affecting your eating habits?
Description

Pain, Eating habit

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1266864
3. Affecting your hygiene/elimination habits?
Description

Pain, Personal Hygiene

Data type

boolean

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0564673
3. Affecting your hygiene/elimination habits?
Description

Pain, Personal Hygiene

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0564673
4. Affecting your ability to move?
Description

Pain, Ability to move

Data type

boolean

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0578670
4. Affecting your ability to move?
Description

Pain, Ability to move

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0578670
5. Affecting your roles in your family?
Description

Pain, Family role

Data type

boolean

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C4721573
5. In what ways?
Description

Pain, Family role

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C4721573
6. Affecting your sexual functioning?
Description

Pain, Sexual function

Data type

boolean

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0278092
6. In what ways?
Description

Pain, Sexual function

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0278092
7. Affecting your physical appearance?
Description

Pain, General appearance

Data type

boolean

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1148438
7. In what ways?
Description

Pain, General appearance

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1148438
8. How has your energy level changed?
Description

Pain, Energy

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1442080
9. Please rate your overall level of concern regarding these physical changes (0-10; 0 = no concern, 10 = greatest concern) - Interviewer
Description

Pain, Psychosocial assessment, Activities of Daily Living

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0001288
9. Please rate your overall level of concern regarding these physical changes (0-10; 0 = no concern, 10 = greatest concern) - Patient
Description

Pain, Psychosocial assessment, Activities of Daily Living

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0001288
9. Please rate your overall level of concern regarding these physical changes (0-10; 0 = no concern, 10 = greatest concern) - Significant Other
Description

Pain, Psychosocial assessment, Activities of Daily Living

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0001288
Emotional
Description

Emotional

Alias
UMLS CUI-1
C0030193
UMLS CUI-2
C1455743
UMLS CUI-3
C0600015
Have you been troubled by feelings of: Depression
Description

Depressive disorder

Data type

boolean

Alias
UMLS CUI [1]
C0011581
Have you been troubled by feelings of: Depression - Describe
Description

Depressive disorder

Data type

text

Alias
UMLS CUI [1]
C0011581
Have you been troubled by feelings of: Frustration/Anger
Description

Frustration, Anger

Data type

boolean

Alias
UMLS CUI [1,1]
C0016770
UMLS CUI [1,2]
C0002957
Have you been troubled by feelings of: Frustration/Anger - Describe
Description

Frustration, Anger

Data type

text

Alias
UMLS CUI [1,1]
C0016770
UMLS CUI [1,2]
C0002957
Have you been troubled by feelings of: Anxiety
Description

Anxiety

Data type

boolean

Alias
UMLS CUI [1]
C0003467
Have you been troubled by feelings of: Anxiety - Describe
Description

Anxiety

Data type

text

Alias
UMLS CUI [1]
C0003467
Have you been troubled by feelings of: Panic Attacks
Description

Panic Attacks

Data type

boolean

Alias
UMLS CUI [1]
C0086769
Have you been troubled by feelings of: Panic Attacks - Describe
Description

Panic Attacks

Data type

text

Alias
UMLS CUI [1]
C0086769
Have you been troubled by feelings of: Mood Swings
Description

Mood swings

Data type

boolean

Alias
UMLS CUI [1]
C0085633
Have you been troubled by feelings of: Mood Swings - Describe
Description

Mood swings

Data type

text

Alias
UMLS CUI [1]
C0085633
Have you been troubled by feelings of: Difficulty Concentrating
Description

Difficulty concentrating

Data type

boolean

Alias
UMLS CUI [1]
C0947509
Have you been troubled by feelings of: Difficulty Concentrating - Describe
Description

Difficulty concentrating

Data type

text

Alias
UMLS CUI [1]
C0947509
Have you been troubled by feelings of: Loss of Motivation
Description

Loss of motivation

Data type

boolean

Alias
UMLS CUI [1]
C0456814
Have you been troubled by feelings of: Loss of Motivation - Describe
Description

Loss of motivation

Data type

text

Alias
UMLS CUI [1]
C0456814
Do you ever see or hear things that others don't?
Description

See or hear things that weren't there

Data type

boolean

Alias
UMLS CUI [1]
C3844000
Do you ever see or hear things that others don't? - Describe
Description

See or hear things that weren't there

Data type

text

Alias
UMLS CUI [1]
C3844000
Are there any medical tests or procedures that frighten you?
Description

Medical procedure, Fear

Data type

boolean

Alias
UMLS CUI [1,1]
C0199171
UMLS CUI [1,2]
C0015726
Are there any medical tests or procedures that frighten you? - Describe
Description

Medical procedure, Fear

Data type

text

Alias
UMLS CUI [1,1]
C0199171
UMLS CUI [1,2]
C0015726
Have you ever thought about hurting yourself or taking your life?
Description

Feeling suicidal

Data type

boolean

Alias
UMLS CUI [1]
C0424000
Have you ever thought about hurting yourself or taking your life? - Describe
Description

Feeling suicidal

Data type

text

Alias
UMLS CUI [1]
C0424000
Please rate your overall level of concern regarding these emotional issues (0-10; 0 = no concern, 10 = greatest concern) - Interviewer
Description

Pain, Psychosocial assessment, Emotional support

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0600015
Please rate your overall level of concern regarding these emotional issues (0-10; 0 = no concern, 10 = greatest concern) - Patient
Description

Pain, Psychosocial assessment, Emotional support

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0600015
Please rate your overall level of concern regarding these emotional issues (0-10; 0 = no concern, 10 = greatest concern) - Significant Other
Description

Pain, Psychosocial assessment, Emotional support

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0600015
Coping
Description

Coping

Alias
UMLS CUI-1
C0030193
UMLS CUI-2
C1455743
UMLS CUI-3
C0009967
Sometimes, doing things we enjoy distracts us from our pain. What activities are you able to do that you enjoy?
Description

Leisure Activities, Joy

Data type

text

Alias
UMLS CUI [1,1]
C0023292
UMLS CUI [1,2]
C4316940
Some people find comfort in spirituality to help them cope with difficult situations. What role does spirituality have in helping you? - Describe
Description

Spirituality

Data type

text

Alias
UMLS CUI [1]
C0237104
Many people in your situation ask "Why did this happen to me?" How have you attempted to "make sense" of your painful experiences? - Describe
Description

Pain, Sense of purpose

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0424089
Past stressful events can impact us in the present. What kinds of stress have you had to handle before? - Describe
Description

Stress

Data type

text

Alias
UMLS CUI [1]
C0038435
What kinds of stress have you had to handle before? - Child abuse?
Description

Child abuse behavior

Data type

boolean

Alias
UMLS CUI [1]
C0008060
What kinds of stress have you had to handle before? - Child abuse? - Describe
Description

Child abuse behavior

Data type

text

Alias
UMLS CUI [1]
C0008060
What kinds of stress have you had to handle before? - Sexual abuse?
Description

Sexual abuse

Data type

boolean

Alias
UMLS CUI [1]
C0282350
What kinds of stress have you had to handle before? - Sexual abuse? - Describe
Description

Sexual abuse

Data type

text

Alias
UMLS CUI [1]
C0282350
What kinds of stress have you had to handle before? - Family violence?
Description

Family Violence

Data type

boolean

Alias
UMLS CUI [1]
C0206072
What kinds of stress have you had to handle before? - Family violence? - Describe
Description

Family Violence

Data type

text

Alias
UMLS CUI [1]
C0206072
Have you ever been in counseling?
Description

Counseling

Data type

boolean

Alias
UMLS CUI [1]
C0010210
What was the focus of your therapy?
Description

Counseling, Attention

Data type

text

Alias
UMLS CUI [1,1]
C0010210
UMLS CUI [1,2]
C0004268
Have you ever attended a support group?
Description

Support Groups

Data type

boolean

Alias
UMLS CUI [1]
C0036606
What kind?
Description

Support Groups

Data type

text

Alias
UMLS CUI [1]
C0036606
How helpful was this?
Description

Support Group, Helpful

Data type

text

Alias
UMLS CUI [1,1]
C0036606
UMLS CUI [1,2]
C3898897
Some people are prescribed medications to help them cope. Which of these have you been prescribed?
Description

Pharmaceutical Preparations

Data type

text

Alias
UMLS CUI [1]
C0013227
Anti-Anxiety medications?
Description

Anti-Anxiety Agents

Data type

boolean

Alias
UMLS CUI [1]
C0040616
Anti-Anxiety medications? - Describe
Description

Anti-Anxiety Agents

Data type

text

Alias
UMLS CUI [1]
C0040616
Anti-Depressant medications?
Description

Antidepressive Agents

Data type

boolean

Alias
UMLS CUI [1]
C0003289
Anti-Depressant medications? - Describe
Description

Antidepressive Agents

Data type

text

Alias
UMLS CUI [1]
C0003289
Pain Medications?
Description

Analgesics

Data type

boolean

Alias
UMLS CUI [1]
C0002771
Pain Medications? - Describe
Description

Analgesics

Data type

text

Alias
UMLS CUI [1]
C0002771
Do you ever take your prescriptions differently than ordered?
Description

Pharmaceutical Preparations, Prescribed

Data type

boolean

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0278329
Do you ever take your prescriptions differently than ordered? - Describe
Description

Pharmaceutical Preparations, Prescribed

Data type

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0278329
Tobacco?
Description

Tobacco use

Data type

boolean

Alias
UMLS CUI [1]
C0543414
Tobacco? - Describe
Description

Tobacco use

Data type

text

Alias
UMLS CUI [1]
C0543414
Alcohol?
Description

Alcohol consumption

Data type

boolean

Alias
UMLS CUI [1]
C0001948
Alcohol? - Describe
Description

Alcohol consumption

Data type

text

Alias
UMLS CUI [1]
C0001948
Recreational Drugs?
Description

Recreational Drugs

Data type

boolean

Alias
UMLS CUI [1]
C0242508
Recreational Drugs? - Describe
Description

Recreational Drugs

Data type

text

Alias
UMLS CUI [1]
C0242508
Have you ever tried to stop using these?
Description

Chemicals, Stop, Attempt

Data type

boolean

Alias
UMLS CUI [1,1]
C0220806
UMLS CUI [1,2]
C2746065
UMLS CUI [1,3]
C1516084
Have you ever tried to stop using these? - Describe
Description

Chemicals, Stop, Attempt

Data type

text

Alias
UMLS CUI [1,1]
C0220806
UMLS CUI [1,2]
C2746065
UMLS CUI [1,3]
C1516084
Has your family worried about your usage of these?
Description

Chemicals, Family, Worried

Data type

boolean

Alias
UMLS CUI [1,1]
C0220806
UMLS CUI [1,2]
C0015576
UMLS CUI [1,3]
C0233481
Has your family worried about your usage of these? - Describe
Description

Chemicals, Family, Worried

Data type

text

Alias
UMLS CUI [1,1]
C0220806
UMLS CUI [1,2]
C0015576
UMLS CUI [1,3]
C0233481
What changes do you expect in your future?- Describe
Description

Future, Changing, Expected

Data type

text

Alias
UMLS CUI [1,1]
C0016884
UMLS CUI [1,2]
C0392747
UMLS CUI [1,3]
C1517001
Overall, how satisfied are you with your present quality of life? - Describe
Description

Quality of fife, Satisfaction

Data type

text

Alias
UMLS CUI [1,1]
C0034380
UMLS CUI [1,2]
C0242428
Please rate your overall level of concern regarding your ability to cope or manage your pain (0-10; 0= no concern, 10 = greatest concern) - Interviewer
Description

Pain, Psychosocial assessment, Coping Behavior

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0009967
Please rate your overall level of concern regarding your ability to cope or manage your pain (0-10; 0= no concern, 10 = greatest concern) - Patient
Description

Pain, Psychosocial assessment, Coping Behavior

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0009967
Please rate your overall level of concern regarding your ability to cope or manage your pain (0-10; 0= no concern, 10 = greatest concern) - Significant Other
Description

Pain, Psychosocial assessment, Coping Behavior

Data type

text

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C1455743
UMLS CUI [1,3]
C0009967
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Similar models

The Psychosocial Pain Assessment Form (PPAF)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Psychosocial Pain Assessment Form
C0030193 (UMLS CUI-1)
C1455743 (UMLS CUI-2)
Patient name
Item
Patient
text
C1299487 (UMLS CUI [1])
Age
Item
Age
text
C0001779 (UMLS CUI [1])
Date in time
Item
Date
date
C0011008 (UMLS CUI [1])
Medical record number
Item
Med. Record #
integer
C1301894 (UMLS CUI [1])
Partner in relationship
Item
Significant Other
text
C0682323 (UMLS CUI [1])
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Primary physician
Item
Primary Physician
text
C1508823 (UMLS CUI [1])
Pain Disorder
Item
Pain Syndrome
text
C0391976 (UMLS CUI [1])
Pain, Duration
Item
Duration of Pain
text
C0030193 (UMLS CUI [1,1])
C0449238 (UMLS CUI [1,2])
Pain, Psychosocial assessment, Health professional
Item
Assessed by
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C1704312 (UMLS CUI [1,3])
Item
Build
text
C0424611 (UMLS CUI [1])
Physique type
Code List
Build
CL Item
Cachectic (1)
CL Item
Thin Medium (2)
CL Item
Heavy (3)
CL Item
Obese (4)
Item
Attire
text
C0009072 (UMLS CUI [1])
Clothing
Code List
Attire
CL Item
Disheveled (1)
CL Item
Hospitalized (2)
CL Item
Casual (3)
CL Item
Professional (4)
Item
Eye Contact
text
C0870532 (UMLS CUI [1])
undefined item
Code List
Eye Contact
CL Item
Avoided (1)
CL Item
Appropriate (2)
CL Item
Stared (3)
Item
Attention
text
C0004268 (UMLS CUI [1])
Attention
Code List
Attention
CL Item
Distracted (1)
CL Item
Focused (2)
CL Item
Hypervigilant (3)
Item
Manner
text
C0683298 (UMLS CUI [1])
Demeanor
Code List
Manner
CL Item
Flat (1)
CL Item
Depressed (2)
CL Item
Distant (3)
CL Item
Cooperation (4)
CL Item
Engaging (5)
CL Item
Humorous (6)
CL Item
Dramatic (7)
CL Item
Agitated (8)
CL Item
Anxious (9)
CL Item
Tearful (10)
CL Item
Sobbing (11)
CL Item
Defensive (12)
CL Item
Sarcastic (13)
CL Item
Argumentative (14)
CL Item
Angry (15)
CL Item
Hostile (16)
Item
Verbal Expression
text
C0150820 (UMLS CUI [1])
Verbal communication
Code List
Verbal Expression
CL Item
Tense (1)
CL Item
Vague (2)
CL Item
Average (3)
CL Item
Articulate (4)
CL Item
Verbose (5)
Item
Reasoning Ability
text
C0582572 (UMLS CUI [1])
undefined item
Code List
Reasoning Ability
CL Item
Impaired (1)
CL Item
Age-Appropriate (2)
CL Item
Advanced (3)
Item
Overall Perspective
text
C3272903 (UMLS CUI [1])
Overall Response
Code List
Overall Perspective
CL Item
Pessimistic (1)
CL Item
Optimistic (2)
CL Item
Unrealistic (3)
CL Item
Realistic (4)
Pain, Psychosocial assessment, Impressions
Item
Impressions
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C1998467 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Interventional procedure
Item
Interventions
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0184661 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Recommendations
Item
Recommendations
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0034866 (UMLS CUI [1,3])
Item Group
Rating (0-10; 0 = no concern, 10 = greatest concern)
C0030193 (UMLS CUI-1)
C1455743 (UMLS CUI-2)
C0681889 (UMLS CUI-3)
Pain, Psychosocial assessment, Economic
Item
Economic - Interviewer
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0013557 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Economic
Item
Economic - Patient
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0013557 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Economic
Item
Economic - Significant Other
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0013557 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Social support
Item
Social Support - Interviewer
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0037438 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Social support
Item
Social Support - Patient
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0037438 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Social support
Item
Social Support - Significant Other
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0037438 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Activities of Daily Living
Item
Activities of daily living - Interviewer
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0001288 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Activities of Daily Living
Item
Activities of daily living - Patient
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0001288 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Activities of Daily Living
Item
Activities of daily living - Significant Other
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0001288 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Emotional Well-being
Item
Emotional - Interviewer
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C2984554 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Emotional Well-being
Item
Emotional - Patient
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C2984554 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Emotional Well-being
Item
Emotional - Significant Other
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C2984554 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Coping Behavior
Item
Coping - Interviewer
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0009967 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Coping Behavior
Item
Coping - Patient
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0009967 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Coping Behavior
Item
Coping - Significant Other
integer
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0009967 (UMLS CUI [1,3])
Item Group
Economic
C0030193 (UMLS CUI-1)
C1455743 (UMLS CUI-2)
C0013557 (UMLS CUI-3)
Item
How are you supporting yourself financially?
text
C0016118 (UMLS CUI [1])
Financial Support
Code List
How are you supporting yourself financially?
CL Item
Work (1)
CL Item
Family (2)
CL Item
Disability (3)
CL Item
Partner (4)
CL Item
Retirement/Pensions (5)
CL Item
Other (6)
CL Item
Friends (7)
CL Item
Savings (8)
Item
Some people we see are concerned about meeting their economic needs. Which of these are worrisome to you?
text
C0013557 (UMLS CUI [1,1])
C2699424 (UMLS CUI [1,2])
Financial Support
Code List
Some people we see are concerned about meeting their economic needs. Which of these are worrisome to you?
CL Item
None  (1)
CL Item
Housing (2)
CL Item
Food  (3)
CL Item
Clothing  (4)
CL Item
Prescriptions  (5)
CL Item
Childcare  (6)
CL Item
Insurance  (7)
CL Item
Medical bills (8)
CL Item
Other (9)
Item
How has your economic situation changed?
text
C0337781 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
Financial Support
Code List
How has your economic situation changed?
CL Item
Better (1)
CL Item
Worse (2)
Economic Status, Changed status
Item
Describe
text
C0337781 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
Economic Status, Changed status, Feeling upset
Item
How upsetting have these changes been to you? Describe
text
C0337781 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
C3887804 (UMLS CUI [1,3])
Economic Status, Patient Wish
Item
What would be different in your life if you could afford to change it? Describe
text
C0337781 (UMLS CUI [1,1])
C0443172 (UMLS CUI [1,2])
C3887804 (UMLS CUI [1,3])
C0747309 (UMLS CUI [1,4])
Item
Please rate your overall level of concern regarding these economic issues (0-10; 0 = no concern at all; 10 = greatest concern) - Interviewer
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0013557 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Economic
Code List
Please rate your overall level of concern regarding these economic issues (0-10; 0 = no concern at all; 10 = greatest concern) - Interviewer
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
5 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item
Please rate your overall level of concern regarding these economic issues (0-10; 0 = no concern at all; 10 = greatest concern) - Patient
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0013557 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Economic
Code List
Please rate your overall level of concern regarding these economic issues (0-10; 0 = no concern at all; 10 = greatest concern) - Patient
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
5 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item
Please rate your overall level of concern regarding these economic issues (0-10; 0 = no concern at all; 10 = greatest concern) - Significant Other
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0013557 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Economic
Code List
Please rate your overall level of concern regarding these economic issues (0-10; 0 = no concern at all; 10 = greatest concern) - Significant Other
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
5 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item Group
Social Support
C0030193 (UMLS CUI-1)
C1455743 (UMLS CUI-2)
C0037438 (UMLS CUI-3)
Item
Who do you turn to when you're uncomfortable or in pain?
text
C0030193 (UMLS CUI [1,1])
C0037438 (UMLS CUI [1,2])
Pain, Social support
Code List
Who do you turn to when you're uncomfortable or in pain?
CL Item
Self (1)
CL Item
Others (2)
CL Item
God (3)
Item
Name
text
C0030193 (UMLS CUI [1,1])
C0037438 (UMLS CUI [1,2])
C0027365 (UMLS CUI [1,3])
Pain, Social support
Code List
Name
Item
Relationship
text
C0030193 (UMLS CUI [1,1])
C0037438 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Pain, Social support
Code List
Relationship
Pain, Social support, Accessibility
Item
How accessible is this person to you?
text
C0030193 (UMLS CUI [1,1])
C0037438 (UMLS CUI [1,2])
C0814423 (UMLS CUI [1,3])
Pain, Social support, Helpful
Item
How helpful is this to you?
text
C0030193 (UMLS CUI [1,1])
C0037438 (UMLS CUI [1,2])
C3898897 (UMLS CUI [1,3])
Feelings, Sharing
Item
How comfortable are you sharing your feelings/fears with your loved ones? What makes this difficult for you? Describe
text
C1527305 (UMLS CUI [1,1])
C0237876 (UMLS CUI [1,2])
Communication, Physicians
Item
How satisfied are you with communication with your doctor/medical team? Describe
text
C0009452 (UMLS CUI [1,1])
C0031831 (UMLS CUI [1,2])
Recent loss of close family member &or friend
Item
Losing people who are important to us affects us deeply. Have you suffered any recent losses?
boolean
C1716700 (UMLS CUI [1])
Recent loss of close family member &or friend
Item
Losing people who are important to us affects us deeply. Have you suffered any recent losses? Describe
text
C1716700 (UMLS CUI [1])
Item
Losing people who are important to us affects us deeply. Have you suffered any recent losses? Describe
text
C1716700 (UMLS CUI [1])
Recent loss of close family member &or friend
Code List
Losing people who are important to us affects us deeply. Have you suffered any recent losses? Describe
CL Item
Breaking up (1)
CL Item
Separation  (2)
CL Item
Divorce (3)
CL Item
Death (4)
CL Item
Moving away (5)
CL Item
Other (6)
Item
Please rate your overall level of concern regarding these social support issues (0-10; 0 = no concern, 10 = greatest concern) - Interviewer
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0600015 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Social support
Code List
Please rate your overall level of concern regarding these social support issues (0-10; 0 = no concern, 10 = greatest concern) - Interviewer
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item
Please rate your overall level of concern regarding these social support issues (0-10; 0 = no concern, 10 = greatest concern) - Patient
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0600015 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Social support
Code List
Please rate your overall level of concern regarding these social support issues (0-10; 0 = no concern, 10 = greatest concern) - Patient
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item
Please rate your overall level of concern regarding these social support issues (0-10; 0 = no concern, 10 = greatest concern) - Significant Other
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0600015 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Social support
Code List
Please rate your overall level of concern regarding these social support issues (0-10; 0 = no concern, 10 = greatest concern) - Significant Other
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item Group
Activities of Daily Living
C0030193 (UMLS CUI-1)
C1455743 (UMLS CUI-2)
C0001288 (UMLS CUI-3)
Pain, Affection, Sleep behavior finding
Item
Often unrelieved pain affects a person's daily routine. How has your pain impacted you in these activities of daily living? 1. Affecting your sleeping patterns?
boolean
C0030193 (UMLS CUI [1,1])
C0474396 (UMLS CUI [1,2])
Item
1. Affecting your sleeping patterns?
text
C0030193 (UMLS CUI [1,1])
C0474396 (UMLS CUI [1,2])
Pain, Affection, Sleep behavior finding
Code List
1. Affecting your sleeping patterns?
CL Item
Frequent napping (1)
CL Item
Nightmares  (2)
CL Item
Drowsiness  (3)
CL Item
Chronic Fatigue (4)
CL Item
Difficulty going to sleep  (5)
CL Item
Difficulty staying asleep  (6)
CL Item
Difficulty waking up  (7)
CL Item
Other (8)
Pain, Eating habit
Item
2. Affecting your eating habits?
boolean
C0030193 (UMLS CUI [1,1])
C1266864 (UMLS CUI [1,2])
Item
2. Affecting your eating habits?
text
C0030193 (UMLS CUI [1,1])
C1266864 (UMLS CUI [1,2])
Pain, Eating habit
Code List
2. Affecting your eating habits?
CL Item
Weight loss/gain  (1)
CL Item
Loss of appetite  (2)
CL Item
Nausea/vomiting  (3)
CL Item
Changes in taste (4)
CL Item
Special Diet  (5)
CL Item
Feeding Tube (6)
CL Item
Difficulty swallowing (7)
CL Item
Other (8)
Pain, Personal Hygiene
Item
3. Affecting your hygiene/elimination habits?
boolean
C0030193 (UMLS CUI [1,1])
C0564673 (UMLS CUI [1,2])
Item
3. Affecting your hygiene/elimination habits?
text
C0030193 (UMLS CUI [1,1])
C0564673 (UMLS CUI [1,2])
Pain, Personal Hygiene
Code List
3. Affecting your hygiene/elimination habits?
CL Item
Diarrhea  (1)
CL Item
Catheter (2)
CL Item
Difficulty Grooming  (3)
CL Item
Difficulty Bathing (4)
CL Item
Constipation (5)
CL Item
Ostomy (6)
CL Item
Incontinence (7)
CL Item
Other (8)
Pain, Ability to move
Item
4. Affecting your ability to move?
boolean
C0030193 (UMLS CUI [1,1])
C0578670 (UMLS CUI [1,2])
Item
4. Affecting your ability to move?
text
C0030193 (UMLS CUI [1,1])
C0578670 (UMLS CUI [1,2])
Pain, Ability to move
Code List
4. Affecting your ability to move?
CL Item
Generalized weakness  (1)
CL Item
Bed bound  (2)
CL Item
Crutches/walker/cane  (3)
CL Item
Getting in/out of car  (4)
CL Item
Lifting/carrying (5)
CL Item
No longer athletic (6)
CL Item
Limited range of motion  (7)
CL Item
Wheel chair  (8)
CL Item
Walking/standing  (9)
CL Item
Climbing stairs  (10)
CL Item
Other (11)
CL Item
S.O.B. (12)
Pain, Family role
Item
5. Affecting your roles in your family?
boolean
C0030193 (UMLS CUI [1,1])
C4721573 (UMLS CUI [1,2])
Pain, Family role
Item
5. In what ways?
text
C0030193 (UMLS CUI [1,1])
C4721573 (UMLS CUI [1,2])
Pain, Sexual function
Item
6. Affecting your sexual functioning?
boolean
C0030193 (UMLS CUI [1,1])
C0278092 (UMLS CUI [1,2])
Pain, Sexual function
Item
6. In what ways?
text
C0030193 (UMLS CUI [1,1])
C0278092 (UMLS CUI [1,2])
Pain, General appearance
Item
7. Affecting your physical appearance?
boolean
C0030193 (UMLS CUI [1,1])
C1148438 (UMLS CUI [1,2])
Pain, General appearance
Item
7. In what ways?
text
C0030193 (UMLS CUI [1,1])
C1148438 (UMLS CUI [1,2])
Item
8. How has your energy level changed?
text
C0030193 (UMLS CUI [1,1])
C1442080 (UMLS CUI [1,2])
Pain, Energy
Code List
8. How has your energy level changed?
CL Item
Less (1)
CL Item
Same (2)
CL Item
Improved (3)
Item
9. Please rate your overall level of concern regarding these physical changes (0-10; 0 = no concern, 10 = greatest concern) - Interviewer
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0001288 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Activities of Daily Living
Code List
9. Please rate your overall level of concern regarding these physical changes (0-10; 0 = no concern, 10 = greatest concern) - Interviewer
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item
9. Please rate your overall level of concern regarding these physical changes (0-10; 0 = no concern, 10 = greatest concern) - Patient
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0001288 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Activities of Daily Living
Code List
9. Please rate your overall level of concern regarding these physical changes (0-10; 0 = no concern, 10 = greatest concern) - Patient
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item
9. Please rate your overall level of concern regarding these physical changes (0-10; 0 = no concern, 10 = greatest concern) - Significant Other
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0001288 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Activities of Daily Living
Code List
9. Please rate your overall level of concern regarding these physical changes (0-10; 0 = no concern, 10 = greatest concern) - Significant Other
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item Group
Emotional
C0030193 (UMLS CUI-1)
C1455743 (UMLS CUI-2)
C0600015 (UMLS CUI-3)
Depressive disorder
Item
Have you been troubled by feelings of: Depression
boolean
C0011581 (UMLS CUI [1])
Depressive disorder
Item
Have you been troubled by feelings of: Depression - Describe
text
C0011581 (UMLS CUI [1])
Frustration, Anger
Item
Have you been troubled by feelings of: Frustration/Anger
boolean
C0016770 (UMLS CUI [1,1])
C0002957 (UMLS CUI [1,2])
Frustration, Anger
Item
Have you been troubled by feelings of: Frustration/Anger - Describe
text
C0016770 (UMLS CUI [1,1])
C0002957 (UMLS CUI [1,2])
Anxiety
Item
Have you been troubled by feelings of: Anxiety
boolean
C0003467 (UMLS CUI [1])
Anxiety
Item
Have you been troubled by feelings of: Anxiety - Describe
text
C0003467 (UMLS CUI [1])
Panic Attacks
Item
Have you been troubled by feelings of: Panic Attacks
boolean
C0086769 (UMLS CUI [1])
Panic Attacks
Item
Have you been troubled by feelings of: Panic Attacks - Describe
text
C0086769 (UMLS CUI [1])
Mood swings
Item
Have you been troubled by feelings of: Mood Swings
boolean
C0085633 (UMLS CUI [1])
Mood swings
Item
Have you been troubled by feelings of: Mood Swings - Describe
text
C0085633 (UMLS CUI [1])
Difficulty concentrating
Item
Have you been troubled by feelings of: Difficulty Concentrating
boolean
C0947509 (UMLS CUI [1])
Difficulty concentrating
Item
Have you been troubled by feelings of: Difficulty Concentrating - Describe
text
C0947509 (UMLS CUI [1])
Loss of motivation
Item
Have you been troubled by feelings of: Loss of Motivation
boolean
C0456814 (UMLS CUI [1])
Loss of motivation
Item
Have you been troubled by feelings of: Loss of Motivation - Describe
text
C0456814 (UMLS CUI [1])
See or hear things that weren't there
Item
Do you ever see or hear things that others don't?
boolean
C3844000 (UMLS CUI [1])
See or hear things that weren't there
Item
Do you ever see or hear things that others don't? - Describe
text
C3844000 (UMLS CUI [1])
Medical procedure, Fear
Item
Are there any medical tests or procedures that frighten you?
boolean
C0199171 (UMLS CUI [1,1])
C0015726 (UMLS CUI [1,2])
Medical procedure, Fear
Item
Are there any medical tests or procedures that frighten you? - Describe
text
C0199171 (UMLS CUI [1,1])
C0015726 (UMLS CUI [1,2])
Feeling suicidal
Item
Have you ever thought about hurting yourself or taking your life?
boolean
C0424000 (UMLS CUI [1])
Feeling suicidal
Item
Have you ever thought about hurting yourself or taking your life? - Describe
text
C0424000 (UMLS CUI [1])
Item
Please rate your overall level of concern regarding these emotional issues (0-10; 0 = no concern, 10 = greatest concern) - Interviewer
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0600015 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Emotional support
Code List
Please rate your overall level of concern regarding these emotional issues (0-10; 0 = no concern, 10 = greatest concern) - Interviewer
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item
Please rate your overall level of concern regarding these emotional issues (0-10; 0 = no concern, 10 = greatest concern) - Patient
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0600015 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Emotional support
Code List
Please rate your overall level of concern regarding these emotional issues (0-10; 0 = no concern, 10 = greatest concern) - Patient
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item
Please rate your overall level of concern regarding these emotional issues (0-10; 0 = no concern, 10 = greatest concern) - Significant Other
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0600015 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Emotional support
Code List
Please rate your overall level of concern regarding these emotional issues (0-10; 0 = no concern, 10 = greatest concern) - Significant Other
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item Group
Coping
C0030193 (UMLS CUI-1)
C1455743 (UMLS CUI-2)
C0009967 (UMLS CUI-3)
Item
Sometimes, doing things we enjoy distracts us from our pain. What activities are you able to do that you enjoy?
text
C0023292 (UMLS CUI [1,1])
C4316940 (UMLS CUI [1,2])
Leisure Activities, Joy
Code List
Sometimes, doing things we enjoy distracts us from our pain. What activities are you able to do that you enjoy?
CL Item
None (1)
CL Item
Family (2)
CL Item
Religion (3)
CL Item
Art/Music  (4)
CL Item
Friends  (5)
CL Item
Gardening  (6)
CL Item
TV (7)
CL Item
Hobbies  (8)
CL Item
Traveling  (9)
CL Item
Pets  (10)
CL Item
Reading  (11)
CL Item
Exercise  (12)
CL Item
Other (13)
Spirituality
Item
Some people find comfort in spirituality to help them cope with difficult situations. What role does spirituality have in helping you? - Describe
text
C0237104 (UMLS CUI [1])
Pain, Sense of purpose
Item
Many people in your situation ask "Why did this happen to me?" How have you attempted to "make sense" of your painful experiences? - Describe
text
C0030193 (UMLS CUI [1,1])
C0424089 (UMLS CUI [1,2])
Stress
Item
Past stressful events can impact us in the present. What kinds of stress have you had to handle before? - Describe
text
C0038435 (UMLS CUI [1])
Child abuse behavior
Item
What kinds of stress have you had to handle before? - Child abuse?
boolean
C0008060 (UMLS CUI [1])
Child abuse behavior
Item
What kinds of stress have you had to handle before? - Child abuse? - Describe
text
C0008060 (UMLS CUI [1])
Sexual abuse
Item
What kinds of stress have you had to handle before? - Sexual abuse?
boolean
C0282350 (UMLS CUI [1])
Sexual abuse
Item
What kinds of stress have you had to handle before? - Sexual abuse? - Describe
text
C0282350 (UMLS CUI [1])
Family Violence
Item
What kinds of stress have you had to handle before? - Family violence?
boolean
C0206072 (UMLS CUI [1])
Family Violence
Item
What kinds of stress have you had to handle before? - Family violence? - Describe
text
C0206072 (UMLS CUI [1])
Counseling
Item
Have you ever been in counseling?
boolean
C0010210 (UMLS CUI [1])
Counseling, Attention
Item
What was the focus of your therapy?
text
C0010210 (UMLS CUI [1,1])
C0004268 (UMLS CUI [1,2])
Support Groups
Item
Have you ever attended a support group?
boolean
C0036606 (UMLS CUI [1])
Support Groups
Item
What kind?
text
C0036606 (UMLS CUI [1])
Support Group, Helpful
Item
How helpful was this?
text
C0036606 (UMLS CUI [1,1])
C3898897 (UMLS CUI [1,2])
Item
Some people are prescribed medications to help them cope. Which of these have you been prescribed?
text
C0013227 (UMLS CUI [1])
Pharmaceutical Preparations
Code List
Some people are prescribed medications to help them cope. Which of these have you been prescribed?
CL Item
None (1)
CL Item
Other (2)
Anti-Anxiety Agents
Item
Anti-Anxiety medications?
boolean
C0040616 (UMLS CUI [1])
Anti-Anxiety Agents
Item
Anti-Anxiety medications? - Describe
text
C0040616 (UMLS CUI [1])
Antidepressive Agents
Item
Anti-Depressant medications?
boolean
C0003289 (UMLS CUI [1])
Antidepressive Agents
Item
Anti-Depressant medications? - Describe
text
C0003289 (UMLS CUI [1])
Analgesics
Item
Pain Medications?
boolean
C0002771 (UMLS CUI [1])
Analgesics
Item
Pain Medications? - Describe
text
C0002771 (UMLS CUI [1])
Pharmaceutical Preparations, Prescribed
Item
Do you ever take your prescriptions differently than ordered?
boolean
C0013227 (UMLS CUI [1,1])
C0278329 (UMLS CUI [1,2])
Pharmaceutical Preparations, Prescribed
Item
Do you ever take your prescriptions differently than ordered? - Describe
text
C0013227 (UMLS CUI [1,1])
C0278329 (UMLS CUI [1,2])
Tobacco use
Item
Tobacco?
boolean
C0543414 (UMLS CUI [1])
Tobacco use
Item
Tobacco? - Describe
text
C0543414 (UMLS CUI [1])
Alcohol consumption
Item
Alcohol?
boolean
C0001948 (UMLS CUI [1])
Alcohol consumption
Item
Alcohol? - Describe
text
C0001948 (UMLS CUI [1])
Recreational Drugs
Item
Recreational Drugs?
boolean
C0242508 (UMLS CUI [1])
Recreational Drugs
Item
Recreational Drugs? - Describe
text
C0242508 (UMLS CUI [1])
Chemicals, Stop, Attempt
Item
Have you ever tried to stop using these?
boolean
C0220806 (UMLS CUI [1,1])
C2746065 (UMLS CUI [1,2])
C1516084 (UMLS CUI [1,3])
Chemicals, Stop, Attempt
Item
Have you ever tried to stop using these? - Describe
text
C0220806 (UMLS CUI [1,1])
C2746065 (UMLS CUI [1,2])
C1516084 (UMLS CUI [1,3])
Chemicals, Family, Worried
Item
Has your family worried about your usage of these?
boolean
C0220806 (UMLS CUI [1,1])
C0015576 (UMLS CUI [1,2])
C0233481 (UMLS CUI [1,3])
Chemicals, Family, Worried
Item
Has your family worried about your usage of these? - Describe
text
C0220806 (UMLS CUI [1,1])
C0015576 (UMLS CUI [1,2])
C0233481 (UMLS CUI [1,3])
Future, Changing, Expected
Item
What changes do you expect in your future?- Describe
text
C0016884 (UMLS CUI [1,1])
C0392747 (UMLS CUI [1,2])
C1517001 (UMLS CUI [1,3])
Quality of fife, Satisfaction
Item
Overall, how satisfied are you with your present quality of life? - Describe
text
C0034380 (UMLS CUI [1,1])
C0242428 (UMLS CUI [1,2])
Item
Please rate your overall level of concern regarding your ability to cope or manage your pain (0-10; 0= no concern, 10 = greatest concern) - Interviewer
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0009967 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Coping Behavior
Code List
Please rate your overall level of concern regarding your ability to cope or manage your pain (0-10; 0= no concern, 10 = greatest concern) - Interviewer
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item
Please rate your overall level of concern regarding your ability to cope or manage your pain (0-10; 0= no concern, 10 = greatest concern) - Patient
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0009967 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Coping Behavior
Code List
Please rate your overall level of concern regarding your ability to cope or manage your pain (0-10; 0= no concern, 10 = greatest concern) - Patient
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
Item
Please rate your overall level of concern regarding your ability to cope or manage your pain (0-10; 0= no concern, 10 = greatest concern) - Significant Other
text
C0030193 (UMLS CUI [1,1])
C1455743 (UMLS CUI [1,2])
C0009967 (UMLS CUI [1,3])
Pain, Psychosocial assessment, Coping Behavior
Code List
Please rate your overall level of concern regarding your ability to cope or manage your pain (0-10; 0= no concern, 10 = greatest concern) - Significant Other
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
CL Item
6 (7)
CL Item
7 (8)
CL Item
8 (9)
CL Item
9 (10)
CL Item
10 (11)
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