Chronic Pain Functional Assessment and Quality of Life Questionnaire
Chronic Pain Functional Assessment and Quality of Life Questionnaire
Evaluate the impact of chronic pain on daily activities, mood, sleep, and function to support treatment planning and track longitudinal outcomes.
Patient full name *
Your answer
Date of birth
Date of assessment
Primary pain location(s)
How long have you had this pain?
Less than 3 months
3–6 months
6–12 months
1–3 years
3–10 years
More than 10 years
Current average pain intensity (past 7 days)
Worst pain in the past 7 days
Least pain in the past 7 days
+ 13 more questions
About this template
Evaluate the impact of chronic pain on daily activities, mood, sleep, and function to support treatment planning and track longitudinal outcomes.
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