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Chronic Pain Management MR#: Pain Assessment Questionnaire

Chronic Pain Management MR#: Pain Assessment Questionnaire 2026

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The document is a Back Pain Questionnaire designed for individuals applying for life insurance with The Wawanesa Life Insurance Company. It collects information about the applicant's history of back or neck pain, including episodes, treatments received, and any related medical investigations or surgeries. The questionnaire also requires a declaration of truthfulness regarding the provided information.

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How to use or fill out Chronic Pain Management MR#: Pain Assessment Questionnaire

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Click ‘Get Form’ to open the Chronic Pain Management MR#: Pain Assessment Questionnaire in our editor.
Begin by entering your name at the top of the form. This personalizes your questionnaire and ensures accurate identification.
For question 1, indicate whether you have experienced pain or discomfort in your back or neck by selecting 'Yes' or 'No'. Provide details about the frequency and duration of episodes in the space provided.
In question 2, specify the area of your back where you feel discomfort by checking the appropriate box: Neck (cervical), Middle (thoracic), or Low (lumbosacral).
Question 3 asks if your pain travels to other areas. If yes, please describe where in the designated space.
Continue with questions regarding treatment history and any investigations related to your back pain. Answer each question truthfully and provide additional details as necessary.
Finally, review your answers for accuracy, sign at the bottom, and date the form before submitting it as instructed.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (68 Votes)
2018	4.4 Satisfied (61 Votes)

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What is the chronic pain grade scale?

The Chronic Pain Grade Questionnaire (CPGQ) assesses the global severity of chronic pain based on intensity and disability3. It provides a categorical grading scheme and numerical self-rating scores for pain intensity and disability, allowing for qualitative changes in chronic pain over time to be analysed3.

How is the pain questionnaire scored?

Most pain scales use numbers from 0 to 10. A score of 0 means no pain, and 10 means the worst pain you have ever felt.

What is the CPG pain scale?

The CPG consists of 7 items providing a score which enables chronic back pain patients to be classified into one of four hierarchical categories corresponding to pain intensity or disability: Grade I, low disability - low pain intensity; Grade II, low disability - high pain intensity; Grade III, high disability -

What is the chronic pain acceptance questionnaire?

The Chronic Pain Acceptance Questionnaire (CPAQ) [32] is a 20-item inventory measuring acceptance of pain. This measure has two subscales: activity engagement (AE) and pain willingness (PW). Participants rate items on a scale from 0 (never true) to 6 (always true).

What does the chronic pain grade questionnaire measure?

The chronic pain grade questionnaire (CPG) is a 7-item instrument frequently used to measure chronic pain in epidemiological studies (Vonkorff et al., 1990, Vonkorff et al., 1992, Elliott et al., 1999).

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How is the chronic pain acceptance questionnaire scored?

Interpretation. The CPAQ-R is a 20-item scale (zero to six response format) used to measure acceptance of pain. An overall score is obtained by adding the items together. Total scores range from zero to 120 with higher scores indicating greater level of acceptance.

What questions are asked during a pain management assessment?

Page 1 Pain history. Where do you have pain/are you sore/ aching or hurting? General medical history. What medical conditions have you been diagnosed with? Review of medications and other. treatments. What medications are you currently taking? Physical impact of pain. How does it feel when you move?

What is the best pain assessment tool for chronic pain?

The Numeric Rating Scale (NRS) is a simple and widely used tool for quantifying pain intensity, where patients rate their pain from 0 (no pain) to 10 (worst possible pain).

Chronic Pain Management MR#: Pain Assessment Questionnaire 2026

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