Prescription Drug Use Questionnaire – Patient Version

If you are currently taking any type of narcotic pain medication (such as Vicodin, Codeine, Percocet, Morphine, Darvon, etc.), please answer all the following questions. Circle either “Y” for a response of “Yes” or “N” for a response of “No” to each question.
1.	Do you have more than one painful condition?	Y	N
2.	Are you disabled by pain (unable to work or participate fully in activities)?	Y	N
3.	Are you receiving any disability payments (such as SSI, or VA disability)?	Y	N
4.	Do you have any current lawsuits or claims related to your pain problem?	Y	N
5.	Have you tried any non-medication treatments for your pain problem (such as physical therapy, TENS, biofeedback)	Y	N
6.	Has your pain been adequately treated over the past 6 months?	Y	N
7.	Do you feel at all angry or mistrustful toward your previous doctors?	Y	N
8.	Have you been given pain medications from more than one clinic over the past 6 months?	Y	N
9.	Have you ever been or do you think you might currently be addicted to pain medications?	Y	N
10.	Has a doctor ever told you that you were addicted to pain medications?	Y	N
11.	Have you had to increase the amount of pain medications you take over the past 6 months?	Y	N
12.	Have you had to call in for more pain medications because your prescription ran out?	Y	N
13.	Have you used the pain medications to help other symptoms such as problems sleeping, anxiety, or depression?	Y	N
14.	Do you save up unused medications in case you might need them in the future?	Y	N
15.	Do you ever use alcohol to help relieve some of the pain?	Y	N
16.	Do you think certain pain medications (such as vicodin, codeine, or percocet) work better for you and you prefer to take them and not others?	Y	N
17.	Have you ever lost your pain medications and needed them replaced?	Y	N
18.	Have you had to visit the emergency room in the past 6 months because of your pain problem?	Y	N
19.	Have you ever had to buy pain medications on the street?	Y	N
20.	Have doctors ever refused to give you the pain medications you felt you needed because of fear that you might abuse them?	Y	N
21.	Is anyone in your family or among your friends concerned that you might be addicted to pain medications?	Y	N
22.	Do any of your family members disagree with your use of pain medications? a	Y	N
23.	Does anyone in your family help to take care of you due to your pain problem? b	Y	N
24.	Does your spouse or significant other have problems with drugs or alcohol?	Y	N
25.	Have those in your family or among your friends ever obtained pain medications for you?	Y	N
26.	Have you ever borrowed pain medications from a friend or family member?	Y	N
27.	Has anyone in your immediate family (father, mother, siblings) ever had a problem with drugs or alcohol?	Y	N
28.	Has anyone in your immediate family (father, mother, siblings) ever had a problem with chronic pain?	Y	N
29.	Have you ever had an alcohol or drug addiction problem?	Y	N
30.	Have you ever been treated for an alcohol or drug abuse problem?	Y	N
31.	Have you ever been taken partially or completely off pain medications to decrease your tolerance?	Y	N

^aRecommended wording revision based on results.

^bRecommend removal of item in future questionnaire revisions.