Language
English (US)
Rapid3 Pain Assessment
Routine assessment of patient index data
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
1. Over the last week, were you able to:
*
Without Any Difficulty
With Some Difficulty
With Much Difficulty
Unable To Do
Dress yourself, including tying shoelaces and doing buttons?
Get in and out of bed?
Lift a full cup or glass to your mouth?
Walk outdoors on flat ground?
Wash and dry your entire body?
Bend down to pick up clothing from the floor?
Turn regular faucets on and off?
Get in and out of a car, bus, train, or airplane?
Walk two miles or three kilometers, if you wish?
Participate in recreational activities and sports as you would like, if you wish?
Functional Status
Functional Status Result
2. How much pain have you had because of your condition OVER THE PAST WEEK? Please indicate below how severe your pain has been (0 = no pain, 10 = severe pain):
*
0
.5
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
Pain Level
Pain Scale
3. Considering all the ways in which illness and health conditions may affect you at this time, please indicate below how you are doing (0 = no pain, 10 = severe pain):
*
0
.5
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
No Level
Overall
Rapid3
Submit
Should be Empty: