Use our readymade template to create your Pain Self Efficacy Questionnaire (PSEQ) for assessing patient's confidence in performing activities despite pain
Create your care assessments
| PSEQ score | Pain Severity | Proposed treatment |
|---|---|---|
| 0-20 | Severe | Immediate initiation |
| 21-40 | Moderate | Consider counseling |
| 41-60 | Mild | Watchful waiting |
| 61-80 | Minimal | May not need treatment |
- Prebuilt template with PSEQ scoring to assess the presence of pain and measure its severity
- 10-item questionnaire that scores each item from “0” (not at all confident) to “6” (completely confident)
- Real-time calculation of PSEQ Score based on the form responses
- Collect patient data and other sensitive healthcare data using our HIPAA compliant online assessment forms
- Compare the scores from the initial screening with that of the followup to track the progression of pain
- Easily create responsive forms that allow patients to complete their assessments on any device at any time
Collect responses from your patients
| Patient ID | 1004 |
| Patient Name | John W |
| Patient Email | johnw@ymail.com |
| Patient Phone Number | 0987654321 |
| Doctor's Name | Dr. Smith |
| Location | New York |
| 1. I can enjoy things, despite the pain. | 4 |
| 2. I can do most of the household chores (e.g. tidying-up, washing dishes, etc.), despite the pain. | 3 |
| 3. I can socialize with my friends or family members as often as I used to do, despite the pain. | 5 |
| 4. I can cope with my pain in most situations. | 4 |
| 5. I can do some form of work, despite the pain. (“work” includes housework, paid and unpaid work). | 3 |
| 6. I can still do many of the things I enjoy doing, such as hobbies or leisure activity, despite pain. | 4 |
| 7. I can cope with my pain without medication. | 2 |
| 8. I can still accomplish most of my goals in life, despite the pain. | 5 |
| 9. I can live a normal lifestyle, despite the pain. | 4 |
| 10. I can gradually become more active, despite the pain. | 3 |
| PSEQ score | 41 |
- Pre-populate patient details such as patient id, name, email etc in the PSEQ assessment form before sharing it with the patients
- Send an email invitation with a secure link for patients to complete their PSEQ assessment form prior to their visit
- Allow patients to save their progress and complete their PSEQ assessment form at a later time without losing any responses
- Set up an email template for your PSEQ assessment and automatically send invitation emails to multiple patients with ease
- Send a confirmation email to the patients with their PSEQ score, diagnosis, next steps when they submit their PSEQ assessment
Track patient responses in Google Sheets
| A | B | C | D | E | |
|---|---|---|---|---|---|
| 1 | Name | Question | Answer | Score | Total Score |
| 2 | John W | 1. I can enjoy things, despite the pain. | 4 | 4 | 41 |
| 3 | John W | 2. I can do most of the household chores (e.g. tidying-up, washing dishes, etc.), despite the pain. | 3 | 3 | 41 |
| 4 | John W | 3. I can socialize with my friends or family members as often as I used to do, despite the pain. | 5 | 5 | 41 |
| 5 | John W | 4. I can cope with my pain in most situations. | 4 | 4 | 41 |
| 6 | John W | 5. I can do some form of work, despite the pain. (“work” includes housework, paid and unpaid work). | 3 | 3 | 41 |
| 7 | John W | 6. I can still do many of the things I enjoy doing, such as hobbies or leisure activity, despite pain. | 4 | 4 | 41 |
| 8 | John W | 7. I can cope with my pain without medication. | 2 | 2 | 41 |
| 9 | John W | 8. I can still accomplish most of my goals in life, despite the pain. | 5 | 5 | 41 |
| 10 | John W | 9. I can live a normal lifestyle, despite the pain. | 4 | 4 | 41 |
| 11 | John W | 10. I can gradually become more active, despite the pain. | 3 | 3 | 41 |
- Export patient responses including the calculated PSEQ score to Google Sheets for easy record-keeping
- Export individual points for 10 items to Google Sheets for data manipulation and analysis for comprehensive insights
- Use pre-built reports to easily keep track of patient progress over time and monitor changes in their pain symptoms
- Receive a copy of the response and the calculated PSEQ score by email whenever a patient submits their PSEQ assessment
- Use data in Google Sheets to integrate with external EHR systems for seamless data transfer
HIPAA compliance
| Patient ID: | 1004 |
| Patient Name: | ****** |
| Patient Email: | ****** |
| Patient Phone Number: | ****** |
| Doctor's Name: | Dr. Smith |
| Location: | New York |
| 1. I can enjoy things, despite the pain.: | 4 |
| 2. I can do most of the household chores (e.g. tidying-up, washing dishes, etc.), despite the pain.: | 3 |
| 3. I can socialize with my friends or family members as often as I used to do, despite the pain.: | 5 |
| 4. I can cope with my pain in most situations. : | 4 |
| 5. I can do some form of work, despite the pain. (“work” includes housework, paid and unpaid work).: | 3 |
| 6. I can still do many of the things I enjoy doing, such as hobbies or leisure activity, despite pain. : | 4 |
| 7. I can cope with my pain without medication. : | 2 |
| 8. I can still accomplish most of my goals in life, despite the pain.: | 5 |
| 9. I can live a normal lifestyle, despite the pain.: | 4 |
| 10. I can gradually become more active, despite the pain. : | 3 |
| PSEQ score: | 41 |
| PSEQ score: | 41 |
- Create a HIPAA compliant PSEQ assessment form to safely collect, store and access patient responses
- Mark fields as Protected Health Information (PHI) to secure sensitive patient data and limit access to PHI
- Automatically mask PHI fields when exporting PSEQ form responses to Google Sheets and sending them on email
- Prepopulate patient details in PSEQ assessments by creating secure prefill links without exposing PHI
- Limit access to patient data only for authorized personnel and minimize the risk of data breaches
These reviews are reproduced without modification from Google Workspace Marketplace.
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