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Appendix IV (i)

                                     SHORT FORM McGILL PAIN QUESTIONNAIRE and PAIN
                                     DIAGRAM
                                     (Reproduced with permission of author © Dr. Ron Melzack, for publication and
                                     distribution)

                                     Date: ______________________________________
                                     Name: _____________________________________
Check the column to indicate the level of your
pain for each word, or leave blank if it does not
apply to you.
                         Mild    Moderate     Severe

1     Throbbing          _____    _____       _____
2     Shooting           _____    _____       _____
3     Stabbing           _____    _____       _____
4     Sharp              _____    _____       _____
5     Cramping           _____    _____       _____
6     Gnawing            _____    _____       _____
7     Hot-burning        _____    _____       _____
8     Aching             _____    _____       _____
9     Heavy              _____    _____       _____
10 Tender                _____    _____       _____
11 Splitting             _____    _____       _____
12 Tiring-Exhausting_____ _____               _____
13 Sickening             _____    _____       _____
14 Fearful               _____    _____       _____
15 Cruel-Punishing _____          _____



Indicate on this line how bad your pain is—at the left end of line means no pain at all, at right end
means worst pain possible.
     No           ________________________________________________                         Worst Possible
    Pain                                                                                       Pain



     S             /33                    A                   /12                    VAS                    /10

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  • 1. Appendix IV (i) SHORT FORM McGILL PAIN QUESTIONNAIRE and PAIN DIAGRAM (Reproduced with permission of author © Dr. Ron Melzack, for publication and distribution) Date: ______________________________________ Name: _____________________________________ Check the column to indicate the level of your pain for each word, or leave blank if it does not apply to you. Mild Moderate Severe 1 Throbbing _____ _____ _____ 2 Shooting _____ _____ _____ 3 Stabbing _____ _____ _____ 4 Sharp _____ _____ _____ 5 Cramping _____ _____ _____ 6 Gnawing _____ _____ _____ 7 Hot-burning _____ _____ _____ 8 Aching _____ _____ _____ 9 Heavy _____ _____ _____ 10 Tender _____ _____ _____ 11 Splitting _____ _____ _____ 12 Tiring-Exhausting_____ _____ _____ 13 Sickening _____ _____ _____ 14 Fearful _____ _____ _____ 15 Cruel-Punishing _____ _____ Indicate on this line how bad your pain is—at the left end of line means no pain at all, at right end means worst pain possible. No ________________________________________________ Worst Possible Pain Pain S /33 A /12 VAS /10