Clinical questionnaires

We need you to complete the following questionnaires to allow our medical team to track your progress and adjust your care accordingly.  

Note that some of the questions might feel repetitive. This is by design to ensure we capture accurate information about your condition. 

If you have any questions or need support to complete these questionnaires feel free to contact us at  patients@levaclinic.com

Estimated completion time: 15-20 minutes

Part 1 - Pain intensity and interference

Reference: Item from Brief Pain Inventory © Copyright 1991 – Charles S. Cleeland, PhD Pain Research Group - All rights reserved.

9. Circle the one number that describes how, during the last week, pain has interfered with your:

Part 2 - Pain self-efficacy

Reference: Michael K. Nicholas PhD, Brian E. McGuire PhD, Ali Asghari PhD

Please rate how confident you are that you can do the following things at present, despite the pain. To indicate your answer select one of the numbers on the scale under each item, where 0 = not at all confident and 6 = completely confident.

Remember, this questionnaire is not asking whether or not you have been doing these things, but rather how confident you are that you can do them at present, despite the pain.

Part 3 - Quality of life 

© EuroQol Research Foundation. EQ-5D™ is a trade mark of the EuroQol Research Foundation

Please click the ONE box that best describes your health TODAY.

We would like to know how good or bad your health is TODAY.

• On  scale from 0 to 100.
• 100 means the best health you can imagine.
• 0 means the worst health you can imagine.

Add below the number representing how good or bad your health is TODAY.