| Always | Sometimes | Rarely | Never | |
| (a.) Acute Painful Episode | 3 | 2 | 1 | 0 |
| (b.) Acute Chest Syndrome | 3 | 2 | 1 | 0 |
| (c.) Acute Priapism | 3 | 2 | 1 | 0 |
| (d.) Acute Stroke | 3 | 2 | 1 | 0 |
| (e.) Pre-operative for General Anesthesia | 3 | 2 | 1 | 0 |
| (f.) Vitreoretinal Surgery | 3 | 2 | 1 | 0 |
| (g.) Other Indications (please specify): | 3 | 2 | 1 | 0 |
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