| RPT |
.|.|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
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