| Child form | Parent form |
|---|---|
| Tell me what pain is. | What word(s) does your child use in regard to pain? |
| Tell me about the hurt you have had before. | Describe the pain experiences your child has had before. |
| Do you tell others when you hurt? If yes, who? | Does your child tell you or others when he/she is hurting? |
| What do you do for yourself when you are hurting? | How do you know when your child is in pain? |
| What do you want others to do for you when you hurt? | How does you child usually react to pain? |
| What don't you want others to do for you when you hurt? | What do you do for your child when he/she is hurting? |
| What helps the most to take your hurt away? | What does your child do for him/herself when he/she is hurting? |
| Is there anything special that you want me to know about you when you hurt? (If yes, have child describe.) | What works best to decrease or take away your child's pain? |
| Is there anything special that you would like me to know about your child and pain? (If yes, describe.) |
Adapted with permission from Hester and Barcus, 1986.