Name
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First Name
Last Name
Date of Birth
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Day
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Month
Year
Date
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Day
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Month
Year
Please rate how confident you are at doing the listed things, despite your pain.
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Rows
0 Not confident
1
2
3
4
5
6 Extremely confident
Enjoying things
Doing household chores
Socialising with friends and family
Coping with my pain
Doing some form of work
Doing hobbies and leisure activities
Coping with my pain without medication
Accomplishing goals in life
Living a normal life
Being active
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Date of Birth
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Day
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Month
Year
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Date
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Day
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Month
Year
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