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Name
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Date of your first or last appointment: *
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MM
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DD
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YYYY
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If you are just starting care with us, enter the date of your first appointment
if you are completing care with us, fill in the date of your last appointment.
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Use 0 through 10 responses to tell us how severe
each issue is in your life.
0 is no impact and 10 is most impact.
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[1]. Does your pain interfere with your normal work inside and outside the home? *
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0.
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10.
0 = work normally 10= Unable to work at all
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[2]. Does your pain interfere with personal care (such as washing, dressing, etc.)? *
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0
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2
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8
9
10
0 = Take care of myself completely 10 = Need help with all my personal care
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[3]. Does your pain interfere with your traveling? *
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0.
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0 = Travel anywhere I like 10 = Only travel to see doctors
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[4]. Does your pain affect your ability to sit or stand? *
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0.
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10.
0 = No problems 10= Can not sit/stand at all
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[5]. Does your pain affect your ability to lift overhead, grasp objects, or reach for things? *
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0.
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0 = No problems 10 = Can not do at all
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[6]. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat? *
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0.
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0 = No problems 10 = Can not do at all
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[7]. Does your pain affect your ability to walk or run? *
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0.
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10.
0 = No problems 10 = Can not walk/run at all
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[8]. Has your income declined since your pain began? *
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0.
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0 = No decline 10 = Lost all income
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[9]. Do you have to take pain medication every day to control your pain? *
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0.
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0 = No medication needed 10 = On pain medication throughout the day
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[10]. Does your pain force your to see doctors much more often than before your pain began? *
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0.
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0 = Never see doctors 10 = See doctors weekly
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[11]. Does your pain interfere with your ability to see the people who are important to you as much as you would like? *
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0.
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0 = No problem 10 = Never see them
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[12]. Does your pain interfere with recreational activities and hobbies that are important to you? *
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0.
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0 = No interference 10 = Total interference
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[13]. Do you need the help of your family and friends to complete everyday tasks (including both work outside the home
and housework) because of your pain? *
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0.
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0 = Never need help 10 = Need help all the time
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[14]. Do you now feel more depressed, tense, or anxious than before your pain began? *
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0.
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0 = No depression/tension 10 = Severe depression/tension
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[15]. Are there emotional problems caused by your pain that interfere with your family, social and or work activities? *
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0.
1.
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8.
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10.
0 = No problems 10 = Severe problems
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If the form does not respond when you hit "Send"
then all entries may not be completed and check above.
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