Step 1 of 520%Name* First Last Date* MM slash DD slash YYYY 1.Pain Intensity* 0-I can tolerate the pain I have without having to use pain medication. 1-The pain is bad, but I can manage without having to take pain medication. 2-Pain medication provides me with complete relief from pain. 3-Pain medication provides me with moderate relief from pain. 4-Pain medication provides me with little relief from pain. 5-Pain medication has no effect on my pain.2. Personal care (e.g. washing, dressing)* 0-I can take care of myself normally without causing increased pain. 1-I can take care of myself normally, but it increases my pain. 2-It is painful to take care of myself, and I am slow and careful. 3-I need help, but I am able to manage most of my personal care. 4-I need help every day in most aspects of my care. 5-I do not get dressed, wash with difficulty, and stay in bed.3. Lifting* 0-I can lift heavy weights without increased pain. 1-I can lift heavy weights, but it causes increased pain. 2-Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned. (e.g. on a table) 3-Pain prevents me from lifting heavy weights, but I can manage to lift medium weights if they are conveniently positioned. 4-I can lift only very light weights. 5-I cannot lift or carry anything at all.4. Walking* 0-Pain does not prevent me from walking any distance. 1-Pain prevents me from walking more than 1 mile. 2-Pain prevents me from walking more than 1/2 mile. 3-Pain presents me from walking more than 1/4 mile. 4-I can only walk with crutches or a cane. 5-I am in bed most of the time and have to crawl to the toilet5. Sitting* 0-I can sit in any chair as long as I like. 1-I can only sit in my favorite chair as long as I like. 2-Pain prevents me from sitting for more than 1 hour. 3-Pain prevents me from sitting for more than 1/2 hour. 4-Pain prevents me from sitting for more than 10 minutes. 5-Pain prevents me from sitting at all.6. Standing* 0-I can stand as long as I want without increased pain. 1-I can stand as long as I want, but it increases my pain. 2-Pain prevents me from standing more than 1 hour. 3-Pain prevents me from standing more than 1/2 hour. 4-Pain prevents me from standing more than 10 minutes. 5-Pain prevents me from standing at all.7. Sleeping* 0-Pain does not prevent m from sleeping well. 1-I can sleep well only by using pain medication. 2-Even when I take pain medication, I sleep less than 6 hours. 3-Even when I take pain medication, I sleep less than 4 hours. 4-Even when I take pain medication, I sleep less than 2 hours. 5-Pain prevents me from sleeping at all.8. Social Life* 0-My social life is normal and does not increase my pain. 1-My social life is normal, but it increases my level of pain. 2-Pain prevents me from participating in more energetic activities (e.g. sports, dancing) 3-Pain prevents me from going out very often. 4-Pain has restricted my social life to my home. 5-I have hardly any social life because of my pain.9. Traveling* 0-I can travel anywhere without increased pain 1-I can travel anywhere, but it increases my pain. 2-My pain restricts my travel over 2 hours. 3-My pain restricts my travel over 1 hour. 4-My pain restricts my travel to short necessary journeys under 1/2 hour. 5-My pain prevents all travel except for visits to the physician/therapist or hospital.10. Employment/ Homemaking* 0-My normal homemaking/ job activities do not cause pain. 1-My normal homemaking/ job activities increase my pain, but I can still perform all that is required of me. 2-I can still perform most of my homemaking/ job duties, but pain prevents me from performing more physically stressful activities (e.g. lifting, vacuuming) 3-Pain prevents me from doing anything but light duties. 4-Pain prevents me from doing even light duties. 5-Pain prevents me from performing any job or homemaking chores.NumberΔ
