• WHYMPI

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Some of the questions in this questionnaire refer to your "significant other".  This does not have to be a romantic partner.  A significant other is a person with whom you feel close.  This can be someone you see regularly or infrequently.  It is important that you identify someone as your "significant other" in order to answer the questions in the second part of this questionnaire.  

  • Please indicate below who your "significant other" is for the purposes of this questionnaire:

  • WHYMPI

    Part A:

  • The following questions will ask you to describe your pain and how it affects your life.  Please read each question carefully and then select one number on the scale under the question to indicate your answer for how that question applies to you.

  • 1. Rate your level of pain at this present moment:*
  • 2. In general, how much does your pain interfere with your day to day activities?:*
  • 3. Since you developed a pain problem, how much has your pain changed your ability to work?*
  • 4. How much has your pain changed the amount of satisfaction or enjoyment you get from participating in social or recreational activities?*
  • 5. How supportive or helpful is your spouse / significant other when it comes to your pain problem?*
  • 6. Rate your overall mood during the past week:*
  • 7. On average, how severe has your pain been during the last week?*
  • 8. How much has your pain changed your ability to participate in recreational and social activities?*
  • 9. How much has your pain changed the amount of satisfaction you get from family-related activities?*
  • 10. How worried about you is your spouse / significant other when it comes to your pain problem?*
  • 11. During the past week, how much control do you feel you have had over your life?*
  • 12. How much suffering do you experience because of your pain?*
  • 13. How much has your pain changed your marriage or other family relationships?*
  • 14. How much has your pain changed the amount of satisfaction or enjoyment you get from your work?*
  • 15. How attentive to you is your spouse or significant other when it comes to your pain?*
  • 16. During the past week, how well do you feel that you have been able to deal with your problems?*
  • 17. How much has your pain changed your ability to do household chores?*
  • 18. During the past week, how irritable have you been?*
  • 19. How much has your pain changed your friendships with people outside your family?*
  • 20. During the past week, how tense or anxious have you been?*

  • WHYMPI

    Part B:

  • In this section, we are interested in knowing how your significant other responds to you when he or she knows that you are in pain.  For each question below, select only one number to indicate how your signficant other generally or typically responds to you when you are in pain.

  • 1. Ignores me:*
  • 2. Asks me what she/he can do to help:*
  • 3. Reads to me:*
  • 4. Expresses irritation at me:*
  • 5. Takes over my jobs or duties:*
  • 6. Talks to me about something else to take my mind off the pain:*
  • 7. Expresses frustration with me:*
  • 8. Tries to get me to rest:*
  • 9. Tries to involve me in some activity:*
  • 10. Expresses anger at me:*
  • 11. Gets me some pain medications:*
  • 12. Encourages me to work on a hobby:*
  • 13. Gets me something to eat or drink:*
  • 14. Turns on the TV to take my mind off of the pain:*

  • WHYMPI

    Part C:

  • Listed below are 18 common activities.  Please indicate how often you do each of these activities by selecting the appropriate number on the scale.  Please answer all 18 items.

  • 1. Wash dishes:*
  • 2. Mow the lawn:*
  • 3. Go out to eat:*
  • 4. Play card games:*
  • 5. Go grocery shopping:*
  • 6. Work in the garden:*
  • 7. Go to a movie:*
  • 8. Visit friends:*
  • 9. Help with house cleaning:*
  • 10. Work on the car:*
  • 11. Take a ride in a car:*
  • 12. Visit relatives:*
  • 13. Prepare a meal:*
  • 14. Wash the car:*
  • 15. Take a trip:*
  • 16. Go to a park or a beach:*
  • 17. Do a load of laundry:*
  • 18. Work on needed house repairs:*
  • Should be Empty: