Disability questionnaires are beneficial tools for both organizations and individuals. Organizations can use disability questionnaires to determine whether or not they need to provide accommodations for employees with disabilities, while individuals can use them to assess their own disability status and seek accommodations if necessary. This Disability Questionnaire Template Form provides a generalized questionnaire that individuals and organizations can use as a starting point when creating their own disability questionnaires. It is important to note that this questionnaire should not be considered comprehensive, and that each situation will require its own unique assessment. Nonetheless, the Disability Questionnaire Template Form can be a useful tool for organizations and individuals alike as they work to understand, accommodate, and empower employees with disabilities.
| Question | Answer |
|---|---|
| Form Name | Disability Questionnaire Template Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | mcgill pain questionnaire online, Copyright, checklist, mcgill pain questionnaire form printable |
PATIENT'S NAME |
|
DATE |
Instructions: Since you have reported that one of your problems is physical pain, the purpose of this checklist is for you to give us an idea about what your physical pain feels like. Each of the words in the left column describes a quality or characteristic that pain can have. So, for each pain quality in the left column, check the number in that row that tells how much of that specific quality your pain has. Rate every pain quality.
PAIN QUALITY |
NONE |
MILD |
MODERATE |
SEVERE |
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1. |
Throbbing |
(0) |
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(1) |
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(2) |
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(3) |
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2. |
Shooting |
(0) |
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(1) |
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(2) |
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(3) |
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3. |
Stabbing |
(0) |
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(1) |
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(2) |
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(3) |
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4. |
Sharp |
(0) |
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(1) |
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(2) |
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(3) |
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5. |
Cramping |
(0) |
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(1) |
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(2) |
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(3) |
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6. |
Gnawing |
(0) |
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(1) |
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(2) |
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(3) |
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7. |
(0) |
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(1) |
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(2) |
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(3) |
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8. |
Aching |
(0) |
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(1) |
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(2) |
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(3) |
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9. |
Heavy |
(0) |
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(1) |
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(2) |
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(3) |
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10. |
Tender |
(0) |
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(1) |
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(2) |
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(3) |
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11. |
Splitting |
(0) |
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(1) |
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(2) |
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(3) |
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12. |
(0) |
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(1) |
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(2) |
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(3) |
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13. |
Sickening |
(0) |
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(1) |
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(2) |
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(3) |
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14. |
Fearful |
(0) |
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(1) |
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(2) |
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(3) |
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15. |
(0) |
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(1) |
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(2) |
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(3) |
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A.PLEASE MAKE AN "X" ON THE LINE BELOW TO SHOW HOW BAD YOUR PAIN IS RIGHT NOW.
NO PAIN |
| WORST POSSIBLE PAIN |
B.PLEASE CHECK THE ONE DESCRIPTOR BELOW THAT BEST DESCRIBES YOUR PRESENT PAIN. 0 NO PAIN
1 MILD
2DISCOMFORTING
3 DISTRESSING |
_ |
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4HORRIBLE
5 EXCRUCIATING
C.IS YOUR PAIN ? (check one word)
Brief Intermittent Continuous
Note: Adapted with permission from the "Short Form McGill Pain Questionnaire". Copyright 1987 Ronald Melzack. S = /33 A/E = /12