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Please take a couple of minutes to fill out this pain assessment. It is designed to give us information as to how your back (or leg) trouble has affected your ability to manage everyday life. Please answer every sention. Please check only one choice in each section that most clearly describes you on an average day.

Pain Intensity Pain Intensity
I can tolerate the pain I have without having to use pain killers
The pain is bad but I can manage without pain killers
Painkillers give me complete relief from pain
Painkillers give me moderate relief from pain
Painkillers give very little relief from pain
Painkillers have no effect on the pain
Personal Care Personal Care
I can look after myself normally 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 manage most of my personal care
I need some help every day in most aspects of self care
I do not get dressed. I wash with difficulty and stay in bed.
Lifting Lifting
I can lift heavy objects without extra pain
I can lift heavy objects but it gives me extra pain
I can't lift heavy objects from off the floor but off a table is OK
I can't lift heavy objects but light to medium ones are OK
I can only lift very light weights
I cannot lift or carry anything at all
Walking Walking
Pain does not prevent me from walking any distance
Pain prevents me from walking more than one mile
Pain prevents me from walking more than on-half mile
Pain prevents me from walking more than one-quarter mile
I can only walk using a cane or crutches
I am in bed or in a chair for most of every day
Sitting Sitting
I can sit in any chair as long as I like
I can sit in my favorite chair as long as I like
Pain prevents me from 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
Standing 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 than one hour
Pain prevents me from standing for more than 30 minutes
Pain prevents me from standing for more than 10 minutes
Pain prevents me from standing at all
Sleeping Sleeping
Pain does not prevent me from sleeping well
I can sleep well only by using medication
When when I take medication I have less than six hours of sleep
Even when I take medication I have less than four hours of sleep
Even when I take medication I have less that two hours of sleep
Pain prevents me from sleeping at all
Sexual Activity (if applicable) Sexual Activity
My sexual activity is normal and causes no extra pain
My sexual activity is normal and causes some extra pain
My sexual activity is nearly normal but is very painful
My sexual activity is severely restricted because of pain
My sexual activity is nearly absent because of pain
Pain prevents any sexual activity at all
Social Life Social Life
My social life is normal and gives me no extra pain
My social life is normal but increases the degree of pain
I can't participate in more energetic activities like tennis
Pain restricts my social life and I don't go out as often
Pain restricts my social life to my home
I have no social lfe because of pain
Traveling Traveling
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 of less than 30 minutes
Pain prevents me from traveling (except to my health practitioner)