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First Name
Last Name
Please rate your level of pain with activity
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0 - No pain
1
3
4
5
6
7
8
9
10 - Very extreme pain
How satisfied are you with the level of care and service provided?
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Please rate your progress with functional activities from start of therapy to present:
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At this point in your treatment, have your therapy goals been met?
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Pain intensity
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0 I can tolerate the pain I have without having to use pain medication
1 The pain is bad, but I can manage without pain medication
2 Pain medication provides me with complete relief
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 relief on my pain
Personal care (washing, dressing, etc.)
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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
Lifting
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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 light to medium weights if they are conveniently positioned
4 I can lift only very light weights
5 I cannot lift or carry anything at all
Walking
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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 prevents 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 toilet
Sitting
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0 I can sit in any chair as long as I want
1 I can only sit in my favorite chair as long as I like
2 Pain prevents me from sitting more than 1 hour
3 Pain prevents me from sitting more than 1/2 hour
4 Pain prevents me from sitting more than 10 minutes
5 Pain prevents me from sitting at all
Standing
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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
Sleeping
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0 Pain does not prevent me 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
Social life
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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. dancing, sports)
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
Traveling
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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 visits to the physician/therapist or hospital
Employment/Homemaking
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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 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
