15 (15)    MH REPORT (601.93)

.|.|West Haven-Yale Multidimensional Pain Inventory||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: 
pain problem interfere with your day to day activities?|    <*Answer_5203*>|Are you retired from work for reasons other than your pain problem?|    <*Answer_5204*>|A3. Since the time you developed a 
pain problem, how much has your pain changed your ability to work?|    <*Answer_5205*>|A4. How much has your pain changed the amount of satisfaction or enjoyment you get from participating in social 
and recreational activities?|    <*Answer_5206*>|A5. How supportive or helpful is your spouse (significant other) to you in relation to your pain?|    <*Answer_5207*>|A6. Rate your overall mood 
during the PAST WEEK.|    <*Answer_5208*>|A7. On the average, how severe has your pain been during the LAST WEEK?|    <*Answer_5209*>|A8. How much has your pain changed your ability to participate in 
recreational and other social activities?|    <*Answer_5210*>|A9. How much has your pain changed the amount of satisfaction you get from family-related activities?|    <*Answer_5211*>|A10. How 
worried is your spouse (significant other) about you in reaction to your pain problem?|    <*Answer_5212*>|A11. During the PAST WEEK, how much control do you feel that you have had over your life?|   
 <*Answer_5213*>|A12. How much SUFFERING do you experience because of your pain?|    <*Answer_5214*>|A13. How much has your pain changed your marriage and other family relationships?|    
<*Answer_5215*>|Are you currently working?|    <*Answer_5216*>|A14. How much has your pain changed the amount of satisfaction or enjoyment you get from work?|    <*Answer_5217*>|A15. How attentive is 
your spouse (significant other) to your pain problem?|    <*Answer_5218*>|A16. During the PAST WEEK, how much do you feel that you've been able to deal with your problems?|    <*Answer_5219*>|A17. 
How much has your pain changed your ability to do household chores?|    <*Answer_5220*>|A18. During the PAST WEEK, how irritable have you been?|    <*Answer_5221*>|A19. How much has your pain changed 
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>| |WHYMPI Scales||Part I|   Interference                       <-Interference->|   Support                            <-Support->|   Pain Severity                     
your friendships with people other than your family?|    <*Answer_5222*>|A20. During the PAST WEEK, how tense or anxious have you been?|    <*Answer_5223*>|B1. Ignores me.|    <*Answer_5225*>|B2. 
Asks me what he/she can do to help.|    <*Answer_5226*>|B3. Reads to me.|    <*Answer_5227*>|B4. Expresses irritation at me.|    <*Answer_5228*>|B5. Takes over my jobs or duties.|    
<*Answer_5229*>|B6. Talks to me about something else to take my mind off the pain.|    <*Answer_5230*>|B7. Expresses frustration with me.|    <*Answer_5231*>|B8. Tries to get me to rest.|    
<*Answer_5232*>|B9. Tries to involve me in some activity.|    <*Answer_5233*>|B10. Expresses anger with me.|    <*Answer_5234*>|B11. Gets me some pain medication.|    <*Answer_5235*>|B12. Encourages 
me to work on a hobby.|    <*Answer_5236*>|B13. Gets me something to eat or drink.|    <*Answer_5237*>|B14. Turns on the TV to take my mind off my pain.|    <*Answer_5238*>|C1. Washes dishes.|    
<*Answer_5239*>|C2. Mow the lawn.|    <*Answer_5240*>|C3. Go out to eat.|    <*Answer_5241*>|C4. Play cards or other games.|    <*Answer_5242*>|C5. Go grocery shopping.|    <*Answer_5243*>|C6. Work 
in the garden.|    <*Answer_5244*>|C7. Go to a movie.|    <*Answer_5245*>|C8. Visit a friend.|    <*Answer_5246*>|C9. Help with the house cleaning.|    <*Answer_5247*>|C10. Work on a car.|    
<*Answer_5248*>|C11. Take a ride in a car.|    <*Answer_5249*>|C12. Visit relatives.|    <*Answer_5250*>|C13. Prepare a meal.|    <*Answer_5251*>|C14. Wash the car.|    <*Answer_5252*>|C15. Take a 
trip.|    <*Answer_5253*>|C16. Go to a park or beach.|    <*Answer_5254*>|C17. Do a load of laundry.|    <*Answer_5255*>|C18. Work on a needed house repair.|    <*Answer_5256*>|||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 
 <-Pain Severity->|   Life-Con
with other diagnostic activities and procedures.||Copyright (c) 1985, Robert D. Kerns, Dennis C. Turk and Thomas E. Rudy.|    $~
trol                       <-Life-Control->|   Affective Distress                 <-Affective Distress->||Part II|   Negative Responses                 <-Negative Responses->|   Solicitous Responses 
              <-Solicitous Responses->|   Distracting Responses              <-Distracting Responses->|
|Part III|   Household Chores                   <-Household Chores->|   Outdoor Work                       <-Outdoor Work->|   Activities Away from Home          <-Activities Away from Home->|   Social Activities                  
<-Social Activities->|   General Activity                   <-General Activity->||Questions and Answers||1.
Please indicate who your significant other is:|    <*Answer_5199*>|Significant
 other:|    <*Answer_5200*>|2. Do you currently live with this person?|    <*Answer_5201*>|A1. Rate the level of your pain at the present moment.|    <*Answer_5202*>|A2. In general, how much does your