Pain Questionnaire - 10 Questions Spam protection, skip this field Name 1. Pain Intensity I have no pain at the moment The pain is very mild at the moment the pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment 2. Personal Care (eg. washing, dressing) I can look after myself noramlly without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but can manage most of my personal care I need help every day in most aspects of self care I do not get dressed, wash with difficulty and stay in bed 3. Lifting I can lift heavy weights without extra pain I can lift heavy weights but it gives me extra pain Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned Pain prevents me from walking more than 500 metres I cannot lift or carry anything I am in bed most of the time 4. Walking Pain does not prevent me walking any distance Pain prevents me from walking more than 2 kilometres Pain prevents me from walking more than 1 kilometre Pain prevents me from walking more than 500 metres I can only walk using a stick or crutches I am in bed most of the time 5. Sitting I can sit in any chair as long as I like I can only sit in my favourite chair as long as I like Pain prevents me sitting more than one hour Pain prevents me from sitting more than 30 minutes Pain prevents me from sitting more than 10 minutes Pain prevents me from sitting at all 6. 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 for more minutes Pain prevents me from standing for more minutes Pain prevents me from standing at all 7. Sleeping My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours sleep Because of pain I have less than 4 hours sleep Because of pain I have less than 2 hours sleep Pain prevents me from sleeping at all 8. Sex Life (optional) My sex life is normal and causes 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 9. Social Life My social life is normal and gives 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 e.g. sport Pain has restricted my social life and I do not go out as often Pain has restricted my social life to my home I have no social life because of pain 10. Travelling I can travel anywhere without pain I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys over two hours Pain restricts me to journeys of less than one hour Pain restricts me to short necessary journeys under 30 minutes Pain prevents me from travelling except to receive treatment
