Questionnaire

Could you please complete this questionnaire? It is designed to give us information as to how your pain has affected your ability to manage in everyday life.

Please answer every section. Mark one box only in each section that most closely describes you today.

Pain intensity

I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is severe at the moment The pain is the worst imaginable at the moment

Personal care (washing, dressing, etc)

I can look after myself normally without extra pain I can look after myself but it is very painful It Is painful to look after myself and 1 am slow I need some help but manage most of my personal care I need help everyday in most aspects of my care I do not get dressed, wash with difficulty and stay in bed

Lifting

I can lift heavy weights without extra pain I can lift heavy weights but It gives extra pain Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positions; for Instance, on the table Pain prevents me from lifting heavy objects but I can manage light to medium weights if they are conveniently positions; for instance, on the table I can only lift light weights I am in bed most of the time and have to crawl to the toilet

Walking

Pain does not prevent me walking any distance Pain prevents me walking more than 1 mile Pain prevents me walking more than a 4 mile Pain prevents me walking more than 100 yards I can only walk using a stick or crutches I am in bed most of the time and have to crawl to the toliet

Sitting

I can sit in any chair as long as like I can sit in my favorite chair as long as i like Pain prevents me from sitting more than 1 hour Pain prevents me from sitting more than half an hour Pain prevents me from sitting more than 10 minutes Pain prevents me from sitting at all

Standing

I can stand as long as I want without extra pain I can stand as long as I want but it gives me extra pain Pain prevents me from standing more than 1 hour Pain prevents me from standing more than a half hour Pain prevents me from standing more than 10 minutes Pain prevents me from standing at all

Sleeping

My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain, I have less than 6 hours of sleep Because of pain, I have less than 4 hours of sleep Because of pain,1 have less than 2 hours of sleep Pain prevents me from sleeping at all

Sex Life

My sex life is normal and causes me no extra pain My sex life is normal but causes some extra pain My sex life is nearly normal but is very painful My sex life is severely restricted by pain My sex life is nearly absent because of pain Pain prevents any sex life at all

Social Life

My social life is normal and causes me no extra pain My social life is normal but increases the degree of pain Pain has no significant effect on my social life apart from limiting my more energetic interests (i.e. sports, etc) Pian has restricted my social life and I do not go out Pain has restricted social life to my house I have no social life because of pain

Traveling

I can travel anywhere without pain I can travel anywhere but it gives extra pain Pain is bad but I manage journeys over 2 hours Pain restricts me to journeys of less than 1 hour Pain restricts me to short journeys less than 30 minutes Pain prevents me from traveling except to receive treatment