|
|
Please Read: This questionnaire is designed to enable us to understand how much your pain has affected you ability to manage your everyday activities. Please answer each Section by circling the ONE CHOICE the most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.
NAME: ___________________________________ DATE: ______________________
SECTION 1—Pain Intensity
q 0 My pain comes and goes and is very mild.
q 1 My pain is mild and does not vary much.
q 2 My pain comes and goes and it is moderate.
q 3 My pain is moderate and does not vary much.
q 4 My pain comes and goes and is severe.
q 5 My pain is severe and does not vary much.
SECTION 2—Fatigue
q 0 My fatigue comes and goes and is very mild.
q 1 My fatigue is mild and does not vary much.
q 2 My fatigue comes and goes and it is moderate.
q 3 My fatigue is moderate and does not vary much.
q 4 My fatigue comes and goes and it is severe.
q 5 My fatigue is sever and does not vary much.
SECTION 3----Personal Care
q 0 I would not have to change my way of washing or dressing in order to avoid pain.
q 1 I do not normally change my way of washing or dressing even though it causes some pain.
q 2 Washing and dressing increases the pain, but I manage not to change my way of
doing it.
q 3 Washing and dressing increase the pain and I find it necessary to change my way of doing it.
q 4 Because of the pain, I am unable to do some washing and dressing without help.
q 5 Because of the pain, I am unable to do any washing or dressing without help.
SECTION 4—Lifting
q 0 I can lift heavy weights without extra pain.
q 1 I can lift heavy weights, but it causes extra pain.
q 2 Pain prevents me from lifting heavy weights off the floor.
q 3 Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned, e.g. on a table.
q 4 Pain prevents me from lifting heavy weights, but I manage light to medium
weights if they are conveniently positioned.
q 5 I can only lift very light weights, at the most.
SECTION 5—Walking
q 0 Pain does not prevent me from walking any distance
q 1 Pain prevents me from walking more than one mile.
q 2 Pain prevents me from walking more than ½ mile.
q 3 Pain prevents me from walking ¼ mile.
q 4 I can only walk while using a cane or on crutches.
q 5 I am in bed most of the time and have to crawl to the toilet.
SECTION 6—Sitting
q 0 I can sit in any chair as long as I like without pain.
q 1 I can only sit in my favorite chair as long as I like.
q 2 Pain prevents me from sitting more than one hour.
q 3 Pain prevents me from sitting more than ½ hour.
q 4 Pain prevents me from sitting more than ten minutes.
q 5 Pain prevents me from sitting at all.
SECTION 7—Standing
q 0 I can stand as long as I want without pain.
q 1 I have some pain while standing, but it does not increase with time.
q 2 I cannot stand for longer than 1 hour without increasing pain.
q 3 I cannot stand for longer than 1/2 hour without increasing pain.
q 4 I cannot stand for longer then 10 minutes without increasing pain.
q 5 I avoid standing, because it increases the pain right away.
SECTION 8--Sleeping
q 0 I have no pain in bed.
q 1 I have pain in bed, but it does not prevent me from sleeping well.
q 2 Because of symptoms, my normal night’s sleep is reduced by less than one- quarter.
q 3 Because of symptoms, my normal night’s sleep is reduced by less than one-half.
q 4 Because of symptoms, my normal night’s sleep is reduced by less than three- quarters.
q 5 My symptoms prevent me form sleeping at all.
SECTION 9—Gastro-Intestinal
q 0 I have no problems with my GI tract.
q 1 I have mild problems with gas, bloating, constipation and/or diarrhea.
q 2 I have mild/moderate problems with gas, bloating, constipation and/or diarrhea.
q 3 I have moderate problems with gas, bloating, constipation, and/or diarrhea.
q 4 I have moderate to severe problems with gas, bloating, constipation, and/or diarrhea.
q 5 I have severe problems with gas, bloating, constipation, and/or diarrhea.
SECTION 9—Social Life
q 0 My social life is normal and gives me no pain.
q 1 My social life is normal, but increases the degree of pain.
q 2 Pain has no significant effect on my social life apart from limiting my more
energetic interests, e.g. dancing, etc.
q 3 Pain has restricted my social life and I do not go out very often.
q 4 Pain has restricted my social life to my home.
q 5 I have hardly any social life because of the pain.
SECTION 10--Traveling
q 0 I get no pain while traveling.
q 1 I get some pain while traveling, but none of my usual forms of travel make it any
worse.
q 2 I get extra pain while traveling but it does not compel me to seek alternate forms
of travel.
q 3 I get extra pain while traveling which compels me to seek alternative forms of
travel.
q 4 Pain restricts all forms of travel except that done lying down.
q 5 Pain restricts all forms of travel.
SECTION 11—Changing Degree of Pain
q 0 My pain is rapidly getting better
q 1 My pain fluctuates, but overall is definitely getting better.
q 2 My pain seems to be getting better, but improvement is slow at present.
q 3 My pain is neither getting better or worse.
q 4 My pain is gradually worsening.
q 5 My pain is rapidly worsening.
SECTION 12—Changing Degree of Fatigue
q 0 My fatigue is rapidly getting better
q 1 My fatigue fluctuates, but overall is definitely getting better.
q 2 My fatigue seems to be getting better, but improvement is slow at present.
q 3 My fatigue is neither getting better or worse.
q 4 My fatigue is gradually worsening.
q 5 My fatigue is rapidly worsening.
(To Be Completed By Doctor: Score_____)