SOAPP®-R

Patient's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Today's Date *

MM

DD

YYYY

How often do you have mood swings? *

Never

Seldom

Sometimes

Often

Very Often

How often have you felt a need for higher doses of medication to treat your pain? *

Never

Seldom

Sometimes

Often

Very Often

How often have you felt impatient with your doctors? *

Never

Seldom

Sometimes

Often

Very Often

How often have you felt that things are just too overwhelming that you can't handle them? *

Never

Seldom

Sometimes

Often

Very Often

How often is there tension in the home? *

Never

Seldom

Sometimes

Often

Very Often

How often have you counted pain pills to see how many are remaining? *

Never

Seldom

Sometimes

Often

Very Often

How often have you been concerned that people will judge you for taking pain medication? *

Never

Seldom

Sometimes

Often

Very Often

How often do you feel bored? *

Never

Seldom

Sometimes

Often

Very Often

How often have you taken more pain medication than you were supposed to? *

Never

Seldom

Sometimes

Often

Very Often

How often have you worried about being left alone? *

Never

Seldom

Sometimes

Often

Very Often

How often have you felt a craving for medication? *

Never

Seldom

Sometimes

Often

Very Often

How often have others expressed concern over your use of medication? *

Never

Seldom

Sometimes

Often

Very Often

How often have any of your close friends had a problem with alcohol or drugs? *

Never

Seldom

Sometimes

Often

Very Often

How often have others told you that you had a bad temper? *

Never

Seldom

Sometimes

Often

Very Often

How often have you felt consumed by the need to get pain medication? *

Never

Seldom

Sometimes

Often

Very Often

How often have you run out of pain medication early? *

Never

Seldom

Sometimes

Often

Very Often

How often have others kept you from getting what you deserve? *

Never

Seldom

Sometimes

Often

Very Often

How often, in your lifetime, have you had legal problems or been arrested? *

Never

Seldom

Sometimes

Often

Very Often

How often have you attended an AA or NA meeting? *

Never

Seldom

Sometimes

Often

Very Often

How often have you been in an argument that was so out of control that someone got hurt? *

Never

Seldom

Sometimes

Often

Very Often

How often have you been sexually abused? *

Never

Seldom

Sometimes

Often

Very Often

How often have others suggested that you have a drug or alcohol problem? *

Never

Seldom

Sometimes

Often

Very Often

How often have you had to borrow pain medications from your family or friends? *

Never

Seldom

Sometimes

Often

Very Often

How often have you been treated for an alcohol or drug problem? *

Never

Seldom

Sometimes

Often

Very Often