Chronic Pain Disability Index Questionnaire
Please complete this questionnaire to help us understand how chronic pain affects your daily life and activities.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate your average pain intensity over the past week.
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
How much has pain interfered with the following activities in the past week?
*
Rows
Not at all
A little
Moderately
Quite a bit
Extremely
Household chores
1
2
3
4
5
Work (including work at home)
6
7
8
9
10
Social activities
11
12
13
14
15
Recreation and hobbies
16
17
18
19
20
Self-care (bathing, dressing, etc.)
21
22
23
24
25
Sleep
26
27
28
29
30
How often do you experience limitations due to pain?
*
Never
Rarely
Sometimes
Often
Always
Which areas of your life are most affected by chronic pain? (Select all that apply)
*
Physical activities
Work or school
Relationships
Mood/emotional well-being
Sleep
Other
In the past week, how would you rate your overall ability to perform daily activities?
*
1
2
3
4
5
Please describe any specific challenges you face due to chronic pain.
Have you received any treatment for your pain in the past 6 months?
*
Yes
No
If yes, please list the treatments you have tried.
Submit
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