Form: Fear of Pain Questionnaire, FPQ-III

male form | female form
1 – Not at all
2 – A little
3 – A fair amount
4 – Very much
5 – Extreme
¹
1
2
3
4
5
1
Being in an automobile accident.
2
Biting your tongue while eating.
3
Breaking your arm.
4
Cutting your tongue licking an envelope.
5
Having a heavy object hit you in the head.
6
Breaking your leg.
7
Hitting a sensitive bone in your elbow-your “funny bone”
8
Having a blood sample drawn with a hypodermic needle.
9
Having someone slam a heavy car door on your hand.
10
Falling down a flight of concrete stairs.
11
Receiving an injection in your arm.
12
Burning your fingers with a match.
13
Breaking your neck.
14
Receiving an injection in your hip/buttocks.
15
Having a deep splinter in the sole of your foot probed and removed with tweezers.
16
Having an eye doctor remove a foreign particle stuck in your eye.
17
Receiving an injection in your mouth.
18
Being burned on your face by a lit cigarette.
19
Getting a paper-cut on your finger.
20
Receiving stitches in your lip.
21
Having a foot doctor remove a wart from your foot with a sharp instrument.
22
Cutting yourself while shaving with a sharp razor.
23
Gulping a hot drink before it has cooled.
24
Getting strong soap in both your eyes while bathing or showering.
25
Having a terminal illness that causes you daily pain.
26
Having a tooth pulled.
27
Vomiting repeatedly because of food poisoning.
28
Having sand or dust blow into your eyes.
29
Having one of your teeth drilled.
30
Having a muscle cramp.

The presented answer sheet is not an original form and is not intended for printing or use as a handout.

The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.