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 momentThe pain is very mild at the momentThe pain is moderate at the momentThe pain is fairly severe at the momentThe pain is severe at the momentThe pain is the worst imaginable at the moment

Personal care (washing, dressing, etc)

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

Lifting

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

Walking

Pain does not prevent me walking any distancePain prevents me walking more than 1 milePain prevents me walking more than a 4 milePain prevents me walking more than 100 yardsI can only walk using a stick or crutchesI am in bed most of the time and have to crawl to the toliet

Sitting

I can sit in any chair as long as likeI can sit in my favorite chair as long as i likePain prevents me from sitting more than 1 hourPain prevents me from sitting more than half an hourPain prevents me from sitting more than 10 minutesPain prevents me from sitting at all

Standing

I can stand as long as I want without extra painI can stand as long as I want but it gives me extra painPain prevents me from standing more than 1 hourPain prevents me from standing more than a half hourPain prevents me from standing more than 10 minutesPain prevents me from standing at all

Sleeping

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

Sex Life

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

Social Life

My social life is normal and causes me no extra painMy social life is normal but increases the degree of painPain 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 outPain has restricted social life to my houseI have no social life because of pain

Traveling

I can travel anywhere without painI can travel anywhere but it gives extra painPain is bad but I manage journeys over 2 hoursPain restricts me to journeys of less than 1 hourPain restricts me to short journeys less than 30 minutesPain prevents me from traveling except to receive treatment

Name*

First Name Last Name