| Please answer each question as honestly as possible. Keep in mind that we are only asking about the past 30 days. There are no right or wrong answers. If you are unsure about how to answer the question, please give the best answer you can. |
| |
| Please answer the questions using the following scale: | Never | Seldom | Sometimes | Often | Very often |
| 0 | 1 | 2 | 3 | 4 |
- In the past 30 days, how often have you had trouble with thinking clearly or had memory problems?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often do people complain that you are not completing necessary tasks? (i.e., doing things that need to be done, such as going to class, work or appointments)
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you had to go to someone other than your prescribing physician to get sufficient pain relief from medications? (i.e., another doctor, the Emergency Room, friends, street sources)
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you taken your medications differently from how they are prescribed?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you seriously thought about hurting yourself?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how much of your time was spent thinking about opioid medications (having enough, taking them, dosing schedule, etc.)?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you been in an argument?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you had trouble controlling your anger (e.g., road rage, screaming, etc.)?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you needed to take pain medications belonging to someone else?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you been worried about how you're handling your medications?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have others been worried about how you're handling your medications?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you had to make an emergency phone call or show up at the clinic without an appointment?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you gotten angry with people?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you had to take more of your medication than prescribed?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you borrowed pain medication from someone else?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you used your pain medicine for symptoms other than for pain (e.g., to help you sleep, improve your mood, or relieve stress)?
| [ ] | [ ] | [ ] | [ ] | [ ] |
- In the past 30 days, how often have you had to visit the Emergency Room?
| [ ] | [ ] | [ ] | [ ] | [ ] |
