| RPT |
.|.|Pain Outcomes Questionnaire||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
affect your self-esteem or self-worth?| <*Answer_5148*>|12. How would you rate your physical activity?| <*Answer_5149*>|13. How would you rate your overall energy?| <*Answer_5150*>|14. How
would you rate your strength and endurance TODAY?| <*Answer_5151*>|15. How would you rate your feelings of depression TODAY?| <*Answer_5152*>|16. How would you rate your feelings of anxiety
TODAY?| <*Answer_5153*>|17. How much do you worry about re-injuring yourself if you are more active?| <*Answer_5154*>|18. How safe do you think it is for you to exercise?|
<*Answer_5155*>|19. Do you have problems concentrating on things TODAY?| <*Answer_5156*>|20. How often do you feel tense?| <*Answer_5157*>|||Information contained in this note is based on a
self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and
procedures.| $~
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|| POQ Scale Raw Inpatient Outpatient| Score Percentile Percentile|<*Answer_999999999999*>| Higher percentile scores denote
Veteran's self-reports of increased symptom| severity when compared to comparison groups of Veterans with pain treated | in inpatient or outpatient multidisciplinary pain settings. ||Questions and Answers||1. Today's date:|
<*Answer_5138*>|2. On a scale of 0 to 10, with 0 being no pain at
all and 10 being the worst possible pain, how would you rate your pain on the AVERAGE during the LAST WEEK?| <*Answer_5139*>|3. Does your pain interfere with your ability to walk?|
<*Answer_5140*>|4. Does your pain interfere with your ability to carry/handle everyday objects such as a bag of groceries or books?| <*Answer_5141*>|5. Does your pain interfere with your ability
to climb stairs?| <*Answer_5142*>|6. Does your pain require you to use a cane, walker, wheelchair or other devices?| <*Answer_5143*>|7. Does your pain interfere with your ability to bathe
yourself?| <*Answer_5144*>|8. Does your pain interfere with your ability to dress yourself?| <*Answer_5145*>|9. Does your pain interfere with your ability to use the bathroom?|
<*Answer_5146*>|10. Does your pain interfere with your ability to manage your personal grooming (for example, combing your hair, brushing your teeth, etc.)?| <*Answer_5147*>|11. Does your pain
|
