Pain Disability Index.MAT

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The Pain Disability Index measures those aspects of your life disrupted most by chronic pain. That is, how much is pain preventing you from doing what you normally do. For each question, answer from 0 to 10 with zero being "no disruption" and ten being "totally disrupted".
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Patient Name* This field is required.
First Name
Last Name
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UniqueID* This field is required.
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Email
example@example.com
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How has pain disrupted your FAMILY/ HOME RESPONSIBILITIES such as chores around the house, yard work, errands or driving others to appointments?* This field is required.0=no disruption/ 10=totally disrupted
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How has pain disrupted your RECREATION such as hobbies, sports and leisure activities? * This field is required.0=no disruption/ 10=totally disrupted
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How has pain disrupted your SOCIAL ACTIVITY such as meeting with friends and family, going out to dinner and other social functions?* This field is required.0=no disruption/ 10=totally disrupted
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How has pain disrupted your OCCUPATION?* This field is required.0=no disruption/ 10=totally disrupted
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How has pain disrupted your SEXUAL BEHAVIOR?0=no disruption/ 10=totally disrupted
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How has pain disrupted your SELF-CARE such as personal maintenance and activities of daily living (i.e., showering, cooking/ cleaning, and getting dressed)?* This field is required.0=no disruption/ 10=totally disrupted
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How has pain disrupted your BASIC LIFE SUPPORT activities such as eating and sleeping?* This field is required.0=no disruption/ 10=totally disrupted
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Today's Provider* This field is required.
Please Select
Please Select
Guy M. Lerner, MD
Leslie Dally, DO
Don Zinno, APRN
Erika Ruth, MD
Craig Rouben, APRN
Tara O'Brien, APRN
Monica Taylor, APRN, PMHNP
Brandi Thomas, APRN, PMHNP
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Screen
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Date
Date
Month
Day
Year
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Pain Disability Index ScoreThe higher the index the greater the person's disability due to pain. Scores > 40 are noteworthy!.
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Grading
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ALERT
Should be Empty: