PAIN OUTCOMES QUESTIONNAIRE

Request Form

If you are a medical practitioner interested in PAIN OUTCOMES MEASUREMENT you may want to utilize the PAIN OUTCOMES QUESTIONNAIRE (POQ; formerly the National Pain Data Bank). The POQ is available in an abbreviated form (the POQ-SF containing 19 core outcomes questions) or in two full versions for both non-VA (POQ) and VA (POQ-VA) use. Each of the full versions consist of 3 separate forms suitable for administration at Intake, Discharge or Stabilization, and Follow Up. The full version also includes pain history and other items.

We also have available a 5-item Pain Treatment Satisfaction scale (PTS) that is included as part of the full POQ-VA, or available as a separate scale.

POQ scoring keys and percentile scores are provided for all POQ versions. To request a copy of the POQ-SF, POQ, POQ-VA, or the PTS, please provide us with the following information. We will retain this data in order to develop a listing of practitioners using the instrument. We may contact you in the future to provide you with updates, new validation information, or to request feedback.

Please provide the following contact information. In addition, please specify which version of the POQ you would like; the POQ-SF (abbreviated version), the non-VA POQ (for non-VA sites), or the VA version (POQ-VA). If you would like to receive a separate copy of the PTS, please indicate that as well.

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
Item(s) Requested:
Comments:

Michael E. Clark, Ph.D., & Ronald J. Gironda, Ph.D.

Chronic Pain Rehabilitation Program
James A. Haley Veterans Affairs Hospital, Tampa, Florida
Revised: 09/06/06