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Chronic Pain Assessment Form
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Chronic Pain Assessment Form
Instructions:
This tool helps assess the severity of your chronic pain and its impact on daily life. Answer based on your experiences over the past week
0 = Not at all
1 = Rarely
2 = Sometimes
3 = Often
4 = Always
Each response earns points. Add up your total score at the end to understand your results.
Section 1: Pain Severity
1. How often did you experience pain this week?
0
1
2
3
4
2. How severe was your pain on an average day?
0 (No pain)
1 (Mild pain)
2 (Moderate pain)
3 (Severe pain)
4 (Unbearable pain)
3. How often did pain affect your sleep?
0
1
2
3
4
Section 2: Impact on Daily Life
4. How often did pain stop you from doing household tasks (e.g., cooking, cleaning)?
0
1
2
3
4
5. How often did pain prevent you from working or completing tasks?
0
1
2
3
4
6. How often did pain limit your ability to care for family members or children?
0
1
2
3
4
Section 3: Emotional Impact
7. How often did pain make you feel frustrated or helpless?
0
1
2
3
4
8. How often did pain stop you from enjoying time with family or friends?
0
1
2
3
4
9. How often did you feel worried about the future because of your pain?
0
1
2
3
4
Add up your total points for all 9 questions:
Interpretation of Results:
0–9 Points: Minimal Impact
Your pain has little effect on your daily life. Focus on maintaining a healthy lifestyle and staying active.
10–18 Points: Mild Impact
Pain is occasionally affecting your routine. Simple interventions like gentle exercises, stretching, or lifestyle changes may help.
19–27 Points: Moderate Impact
Pain is interfering with daily activities and emotional well-being. Professional evaluation and pain management strategies are recommended.
28–36 Points: Severe Impact
Pain is significantly affecting your quality of life. Immediate medical support is strongly recommended to address pain and its impact.
What’s Next?
If your score indicates moderate to severe pain impact, the Zan Center provides specialized support to manage chronic pain effectively with culturally sensitive care.
Disclaimer: This tool is for informational purposes only. Please consult a healthcare provider for an accurate diagnosis and treatment plan. This scal is a general modified guide tool quationares for Pakistani populations.
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