Fixing You® Pain Disability Test
This test is designed to measure how much your life is disrupted by chronic pain. It's important to measure how much pain is preventing you from doing what you normally do in everyday life. Please be sure to take this test both before beginning the program and again after completing the program.
How much pain do you experience when performing family/home responsibilities? Such as: yard work, driving kids to school, running errands, doing laundry and dishes.
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Please Select
0 - No pain at all
1
2
3
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5
6
7
8
9
10 - Worst possible pain
How much pain do you experience when performing recreational activities? Such as: hobbies, sports, and other leisure activities.
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Please Select
0 - No pain at all
1
2
3
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5
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7
8
9
10 - Worst possible pain
How much pain do you experience during social activities? Such as: parties, theater, concerts, dining out, etc.
*
Please Select
0 - No pain at all
1
2
3
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7
8
9
10 - Worst possible pain
How much pain do you experience when performing your primary occupation? Also includes volunteer work and stay-at-home work.
*
Please Select
0 - No pain at all
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2
3
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7
8
9
10 - Worst possible pain
How much pain do you experience during procreative activity? This refers to the frequency and quality of that part of your life.
*
Please Select
0 - No pain at all
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2
3
4
5
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7
8
9
10 - Worst possible pain
How much pain do you experience while performing self-care? Such as: taking a shower, getting dressed, etc.
*
Please Select
0 - No pain at all
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2
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9
10 - Worst possible pain
How much pain do you experience during standard life support activities? Such as: eating, sleeping, and breathing.
*
Please Select
0 - No pain at all
1
2
3
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5
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7
8
9
10 - Worst possible pain
What part of your body hurts the most?
*
Please Select
Back
Hip
Knee
Foot/Ankle
Neck/Headaches
Shoulder
Which email address should we send your test results?
*
example@example.com
First Name
*
Sum
What's My Score?
Should be Empty: