APS Patient Outcome Questionnaire (APS-POQ-R) APS Patient Outcome Questionnaire (APS-POQ-R)
APS Patient Outcome Questionnaire (APS-POQ-R) APS Patient Outcome Questionnaire (APS-POQ-R)
APS Patient Outcome Questionnaire (APS-POQ-R) APS Patient Outcome Questionnaire (APS-POQ-R)
2. On this scale, please indicate the worst pain you had in the first 24 hours:
0 1 2 3 4 5 6 7 8 9 10
no pain worst pain possible
3. On this scale, please indicate the average pain you had in the first 24 hours:
0 1 2 3 4 5 6 7 8 9 10
no pain worst pain possible
4. How often were you in severe pain in the first 24 hours? Please mark your best estimate of the percentage
of time you experienced severe pain:
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Never in Always in
severe pain severe pain
5. Mark the one number below that best describes how much pain interfered or prevented you from:
a. Doing activities in bed such as turning, sitting up, repositioning.
0 1 2 3 4 5 6 7 8 9 10
Does not interfere Completely interferes
b. Doing activities out of bed such as walking, sitting in a chair, standing at the sink.
On 0 1 2 3 4 5 6 7 8 9 10
bedrest Does not interfere Completely interferes
c. Falling asleep
0 1 2 3 4 5 6 7 8 9 10
Does not interfere Completely interferes
d. Staying asleep
0 1 2 3 4 5 6 7 8 9 10
Does not interfere Completely interferes
6. Pain can affect our mood and emotions. On this scale, please circle the one number that best shows how
much the pain caused you to feel:
a. Anxious 0 1 2 3 4 5 6 7 8 9 10
Not at all Extremely
b. Depressed 0 1 2 3 4 5 6 7 8 9 10
Not at all Extremely
c. Frightened 0 1 2 3 4 5 6 7 8 9 10
Not at all Extremely
d. Helpless 0 1 2 3 4 5 6 7 8 9 10
Not at all Extremely
8. In the first 24 hours, how much pain relief have you received? Please circle the one percentage that best
shows how much relief you have received from all of your pain treatments combined (medicine and
non-medicine treatments):
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No Relief Complete Relief
9. Were you allowed to participate in decisions about your pain treatment as much as you wanted to?
0 1 2 3 4 5 6 7 8 9 10
Not at all Very much so
10. Mark the one number that best shows how satisfied you are with the results of your pain treatment while
in the hospital:
0 1 2 3 4 5 6 7 8 9 10
Extremely Extremely
Dissatisfied Satisfied
11. Did you receive any information about your pain treatment options? No Yes
a. If yes, please mark the number that best shows how helpful the information was:
0 1 2 3 4 5 6 7 8 9 10
Not at all helpful Extremely helpful
12. Did you use any non-medicine methods to relieve your pain? No Yes
a. If yes, mark all that apply:
cold pack meditation deep breathing
listen to music distraction (such as watching TV, reading)
prayer heat relaxation
imagery or visualization walking massage
other (please describe)
13. How often did a nurse or doctor encourage you to use non-medicine methods?
Never Sometimes Often