Section 1: Pain Intensity

I have no pain at the moment. [0 points]

The pain is very mild at the moment . [ 1 point ]

The pain is moderate at the moment . [ 2 points ]

The pain is fairly severe at the moment. [3 points ]

The pain is very severe at the moment. [4 points]

The pain is the worst imaginable at the moment. [5 points]

Section 6: Standing (Remember, standing is NOT walking.)

I can stand as long as I want without extra pain. [0 points]

I can stand as long as I want but it gives me extra pain. [1 point ]

Pain prevents me from standing for more than 1 hour. [2 points]

Pain prevents me from standing for more than 30 minutes. [3 points]

Pain prevents me from standing for more than 10 minutes. [4 points]

Pain prevents me from standing at all. [5 points]

Section 2: Personal Care

I can look after myself normally without causing extra pain. [0 points]

I can look after myself normally but it causes extra pain. [1 point ]

It is painful to look after myself and I am slow and careful. [2 points]

I need some help but manage most of my personal care. [3 points]

I need help every day in most aspects of self care. [4 points]

I do not get dressed wash with difficulty and stay in bed. [5 points]

Section 7: Sleeping

My sleep is never disturbed by pain. [0 points]

My sleep is occasionally disturbed by pain. [1 point ]

Because of pain, I have less than 6 hours of sleep. [2 points]

Because of pain, I have less than 4 hours of sleep. [3 points]

Because of pain, I have less than 2 hours of sleep. [4 points]

Pain prevents me from sleeping at all. [5 points]

Section 3: Lifting

I can lift heavy weights without extra pain. [0 points]

I can lift heavy weights but it gives extra pain. [1 point]

Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned. eg. on a table. [2 points]

Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. [ 3 points ]

I can lift only very light weights. [4 points]

I cannot lift or carry anything at all. [5 points]

Section 8: Sex Life (by pain = for fear of causing pain)

My sex life is normal and causes no extra pain. [0 points]

My sex life is normal but causes some extra pain. [1 point]

My sex life is nearly normal but is very painful. [2 points]

My sex life is severely restricted by pain. [ 3 points ]

My sex life is nearly absent because of pain. [4 points]

Pain prevents any sex life at all. [5 points]

Section 4: Walking (bad question)

Pain does not prevent me walking any distance. [0 points]

Pain prevents me walking more than 1 mile. [ 1 point ]

Pain prevents me walking more than 1/2 mile. [2 points]

Pain prevents me walking more than 100 Yard. [3 points]

I can only walk using a stick or crutches. [4 points]

I am in bed most of the time and have to crawl to the toilet. [5 points]

Section 9: Social Life

My social life is normal and gives me no extra pain. [0 points]

My social life is normal but increases the degree of pain. [1 point]

Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., sports, etc. [ 2 points ]

Pain has restricted my social life and I do not go out as often. [3 points]

Pain has restricted my social life to my home. [4 points]

I have no social life because of pain. [5 points]

Section 5: Sitting ("Favorite chair" includes a recliner.)

I can sit in any chair as long as I like. [0 points]

I can only sit in my favorite chair as long as I like. [ 1 point ]

Pain prevents me sitting more than 1 hour. [2 points]

Pain prevents me from sitting more than 1/2 hour. [3 points]

Pain prevents me from sitting more than 10 minutes. [4 points]

Pain prevents me from sitting at all. [5 points]

Section 10: Traveling

I can travel anywhere without extra pain. [0 points]

I can travel anywhere but it gives me extra pain. [1 point]

Pain is bad but I manage journeys over 2 hours. [ 2 points ]

Pain restricts me to journeys of less than 1 hour. [3 points]

Pain restricts me to short necessary journeys under 30 minutes. [4 points]

Pain prevents me from traveling except to receive treatment. [5 points]