Patient Qs This information will let us know more about you. Patient Qs This information will let us know more about you. "*" indicates required fields Step 1 of 2 - PERSONAL INFORMATION 50% Patient’s Name*Date of birth:* MM slash DD slash YYYY Sex* Male Female How often do you have mood swings?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you felt a need for higher doses of medication to treat your pain?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you felt impatient with your doctors?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you felt that things are just too overwhelming that you can't handle them?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often is there tension in the home?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you counted pain pills to see how many are remaining?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you been concerned that people will judge you for taking pain medication?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often do you feel bored?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you taken more pain medication than you were supposed to?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you worried about being left alone?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you felt a craving for medication?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have others expressed concern over your use of medication?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have any of your close friends had a problem with alcohol or drugs?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have others told you that you had a bad temper?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you felt consumed by the need to get pain medication?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you run out of pain medication early?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have others kept you from getting what you deserve?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often, in your lifetime, have you had legal problems or been arrested?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you attended an AA or NA meeting?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you been in an argument that was so out of control that someone got hurt?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you been sexually abused?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have others suggested that you have a drug or alcohol problem?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you had to borrow pain medications from your family or friends?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you been treated for an alcohol or drug problem?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often How often have you been treated for an alcohol or drug problem?* 0 Never 1 Seldom 2 Sometimes 3 Often 4 Very Often Please include any additional information you wish about the above answers. Thank you. Δ
