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John S. | Dec. 15, 2025
In the last 24 hours, have you had any pain?
I have not had pain in the past 24 hours
I have had pain in the past 24 hours
Over the last 24 hours, were you limited in your daily activities?
Choose one of the following that best describes the severity of your pain in the last 24 hours on a 1-5 scale, using the faces as a guide:
Did your pain cause you to go to the emergency room?
I did get emergency treatment
I did not seek additional treatment.
Did pain limit your activities over the last 24 hours?
Activities were not limited.
Activities were mildly limited.
Activities were moderately limited.
Activities were severely limited.
I could not do usual activities.
Which activities did your pain prevent you from participating in? (Select all that apply)
Over the last 24 hours, did you take your scheduled/maintenance medications as prescribed?
How many acute/rescue medications did you use?
Did you participate in your recommended treatments? (Eg: Exercises/PT, Ice/Heat, Mindfulness/CBT)
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