Sickle Cell Pain Action Plan: Pictogram and CIRF

Pictograms- Transparency and Translucency

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* 1. Personal Information

Highest academic degree achieved: High school, Associates, Bachelors, Masters, PhD, MD/DO

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* 2. Do you have sickle cell disease?

I have sickle cell disease

I frequently care for someone with sickle cell disease

Not applicable to me

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* 3. Your Date of Birth

Date

Date

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* 4. Which of the images best depicts a child: "Sleeps well"?

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* 5. Which of the images best depicts a child: "Sleeping less or trouble sleeping"?

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* 6. Which of the images best depicts a child: "Not sleeping"?

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* 7. Which of the images best depicts a child: "No headache"?

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* 8. Which of the images best depicts a child: "Worse headache or severe headache"?

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* 9. Which of the images best depicts a child: "No pain or Baseline pain"?

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* 10. Which of the images best depicts a child: "Mild pain"?

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* 11. Which of the images best depicts a child: "Severe pain"?

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* 12. Which of the images best depicts a child: "Active"?

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* 13. Which of the images best depicts a child: "Less active"?

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* 14. Which of the images best depicts a child: "Not active"?

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* 15. Which of the images best depicts a child: "Able to work or learn"?

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* 16. Which of the images best depicts a child: "Less able to work or learn"?

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* 17. Which of the images best depicts a child: "Not able to work or learn"?

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* 18. Which of the images best depicts a child: "Medicines control pain"?

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* 19. Which of the images best depicts a child: "More medicines to control pain"?

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* 20. Which of the images best depicts a child: "Medicines NOT control pain"?

For the following images, please choose how well you think the words describe the images (from 1-no relationship to 7-very strong relationship)

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* 21. Sleeps well

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 22. Sleeps less or Trouble sleeping

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 23. Not sleeping

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 24. No headache

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 25. Mild headache

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 26. Worse headache or Severe headache

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 27. No pain or Baseline pain

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 28. Mild pain

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 29. Severe pain

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 30. Active

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 31. Less active

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 32. Not active

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 33. Able to work or learn

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 34. Less able to work or learn

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 35. Not able to work or learn

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 36. Medicines control pain

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 37. More medicines to control pain

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 38. Medicines NOT control pain

1- no relationship

7- very strong relationship

Clear

i We adjusted the number you entered based on the slider’s scale.