| Item
|
Never |
Seldom |
Sometimes |
Often |
Very often
|
| How often do you have mood swings?
|
0 |
1 |
2 |
3 |
4
|
| How often have you felt a need for higher doses of medication to treat your pain?
|
0 |
1 |
2 |
3 |
4
|
| How often have you felt impatient with your doctors?
|
0 |
1 |
2 |
3 |
4
|
| How often have you felt that things are just too overwhelming that you can't handle them?
|
0 |
1 |
2 |
3 |
4
|
| How often is there tension in the home?
|
0 |
1 |
2 |
3 |
4
|
| How often have you counted pain pills to see how many are remaining?
|
0 |
1 |
2 |
3 |
4
|
| How often have you been concerned that people will judge you for taking pain medication?
|
0 |
1 |
2 |
3 |
4
|
| How often do you feel bored?
|
0 |
1 |
2 |
3 |
4
|
| How often have you taken more pain medication than you were supposed to?
|
0 |
1 |
2 |
3 |
4
|
| How often have you worried about being left alone?
|
0 |
1 |
2 |
3 |
4
|
| How often have you felt a craving for medication?
|
0 |
1 |
2 |
3 |
4
|
| How often have others expressed concern over your use of medication?
|
0 |
1 |
2 |
3 |
4
|
| How often have any of your close friends had a problem with alcohol or drugs?
|
0 |
1 |
2 |
3 |
4
|
| How often have others told you that you had a bad temper?
|
0 |
1 |
2 |
3 |
4
|
| How often have you felt consumed by the need to get pain medication?
|
0 |
1 |
2 |
3 |
4
|
| How often have you run out of pain medication early?
|
0 |
1 |
2 |
3 |
4
|
| How often have others kept you from getting what you deserve?
|
0 |
1 |
2 |
3 |
4
|
| How often, in your lifetime, have you had legal problems or been arrested?
|
0 |
1 |
2 |
3 |
4
|
| How often have you attended an AA or NA meeting?
|
0 |
1 |
2 |
3 |
4
|
| How often have you been in an argument that was so out of control that someone got hurt?
|
0 |
1 |
2 |
3 |
4
|
| How often have you been sexually abused?
|
0 |
1 |
2 |
3 |
4
|
| How often have others suggested that you have a drug or alcohol problem?
|
0 |
1 |
2 |
3 |
4
|
| How often have you had to borrow pain medications from your family or friends?
|
0 |
1 |
2 |
3 |
4
|
| How often have you been treated for an alcohol or drug problem?
|
0 |
1 |
2 |
3 |
4
|
