Chronic Pain Assessment Form

Instructions:

This tool helps assess the severity of your chronic pain and its impact on daily life. Answer based on your experiences over the past week

0 = Not at all

1 = Rarely

2 = Sometimes

3 = Often

4 = Always

Each response earns points. Add up your total score at the end to understand your results.

Section 1: Pain Severity

Section 2: Impact on Daily Life

Section 3: Emotional Impact

Interpretation of Results:

0–9 Points: Minimal Impact

Your pain has little effect on your daily life. Focus on maintaining a healthy lifestyle and staying active.

10–18 Points: Mild Impact

Pain is occasionally affecting your routine. Simple interventions like gentle exercises, stretching, or lifestyle changes may help.

19–27 Points: Moderate Impact

Pain is interfering with daily activities and emotional well-being. Professional evaluation and pain management strategies are recommended.

28–36 Points: Severe Impact

Pain is significantly affecting your quality of life. Immediate medical support is strongly recommended to address pain and its impact.

What’s Next?

If your score indicates moderate to severe pain impact, the Zan Center provides specialized support to manage chronic pain effectively with culturally sensitive care.

Disclaimer: This tool is for informational purposes only. Please consult a healthcare provider for an accurate diagnosis and treatment plan. This scale is a general modified guide for Pakistani population.