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12
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1
Name
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Please fill in your name
First Name
Last Name
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2
Date
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Date
Year
Month
Day
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3
1. How long have you had your current pain problems?
*
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Select one.
0-1 week
1-2 weeks
3-4 weeks
4-5 weeks
6-8 weeks
9-11 weeks
3-6 months
6-9 months
9-12 months
Over 1 year
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4
2. How would you rate the pain that you have had during the past week?
*
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0 = No pain, and 10 = Pain as bad as it could be
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5
3. I can do light work (or home duties) for an hour.
*
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0 = Not at all 10 = Without any difficulty
0
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6
4. I can sleep at night.
*
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0 = No at all 10 = Without any difficulty
0
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7
5. How tense or anxious have you felt in the past week?
*
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0 = Absolutely calm and relaxed 10 = As tense anxious I've ever felt
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8
6. How much have you been bothered by feeling depressed in the past week?
*
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0 = Not at all 10 = Extremely
0
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9
7. In your view, how large is the risk that your current pain may become persistent?
*
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0 = No risk 10 = Very large risk
0
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10
8. In your estimation, what are the chances you will be working your normal duties (at home or work)
*
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0 = No chance 10 = Very large chance
0
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11
9. An increase in pain is an indication that I should stop what I’m doing until the pain decreases.
*
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0 = Completely disagree 10 = Completely agree
0
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12
10. I should not do my normal work (at work or home duties) with my present pain.
*
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0 = Completely disagree 10 = Completely agree
0
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13
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