General Questions
Questions about the Patient Survey Data Entry Form
Questions abou the Patient Survey Summary report

The following questions are about pain you experienced during the first 24 hours in the hospital or after your operation.

1.  Did you experience any pain in the first 24 hours (after surgery) or being admitted to the hospital? 

If you answered no to #1, please stop now.  If you answered yes, complete the rest of the questionnaire.
        
2.  On this scale, how much pain are you having right now?

3.  On this scale, please indicate the worst pain you had in the first 24 hours.
 
4.  On this scale, please indicate the least pain you had in the first 24 hours.

5.  How often were you in moderate to severe pain in the first 24 hours?
 ___ Always ___ Almost always ___ Often ___ Almost never ___ Never

6. Circle the number below that best describes how, during that first 24 hours, how pain interfered with your:
 
A.  General activity
B.  Mood
C.  Walking ability
D.  Eating
E.  Sleep
F.  Coughing and deep breathing

7.  Did you have any side effects from pain medicine?  ___ Yes ___ No

 If yes, check all that apply: 
___ Drowsiness 
___ Nausea or vomiting
___ Constipation 
___ Itchiness
___ Other (describe) _________________________

8.  Did you use any non-drug methods to relieve your pain? ___ Yes ___ No

 If yes, check all that apply:  
___ Relaxation  
___ Walking
___ Mediation 
___ Imagery or visualization
___ Heating pad 
___ Therapeutic touch
___ Cold pack   
___ Deep breathing
___ Other (describe) _______________________

9.  Select the phrase that indicates how satisfied or dissatisfied you are with the results of your pain treatment overall. 
___ Very dissatisfied
___ Dissatisfied
___ Slightly dissatisfied
___ Slightly satisfied
___ Satisfied
___ Very satisfied

10.  If you were satisfied, what is it that made you satisfied (check all that apply)?       
___ I didn’t have much pain
___ The pain medicine relieved my pain
___ I felt I had control over my pain
___ The doctors and nurses seemed to care a lot about my comfort
___ The doctors and nurses were prepared to manage my pain
___ Other (describe) _____________________________

11. If you were not satisfied with your pain treatment in any way, please explain why (check all that apply).   
___ I had a lot of pain
___ The pain medicine did not help
___ I felt I had no control over my pain
___ The doctors and nurses did not seem to care about my pain
___ The doctors and nurses were not prepared to manage my pain
___ I had side effects from my pain medicine
___ Other (describe) ______________________________

12.  Please respond to the next seven items by check the box under the number that comes closest to how much you agree with that item.  There are no right or wrong answers; we just want to know what you think.

A. Pain medicine cannot really control pain. 

B. People get addicted to pain medicine easily.

C. Good patients avoid talking about pain.

D. It is easier to put up with pain than to deal with the side effects that come from pain medicine.

E. Complaints of pain could waste time with my physician that could be spent on other things.

F. Pain medicine should be “saved” in case the pain gets worse.

G. The experience of pain is a sign that  illness has gotten worse.

13.  Earlier in your care, did a physician or nurse make it clear to you that we consider treatment of pain very important and that you should be sure to tell them when you have pain?
___ Yes               ___ No

Please place your completed survey in the envelope provided, seal it, and the person 
who gave it to you will come back and pick it up.

Thank you very much for your time and willingness 
to give us feedback on your care.