Pain Intensity |
Score |
I have no pain at the moment |
01 |
The pain is very mild at the moment |
02 |
The pain is moderate at the moment |
03 |
The pain is fairly severe at the moment |
04 |
The pain is very severe at the moment |
05 |
The pain is the worst imaginable at the moment |
06 |
|
|
Personal care (washing, dressing etc) |
|
I can look after myself normally without causing extra pain |
01 |
I can look after myself normally but it causes extra pain |
02 |
It is painful to look after myself and I am slow and careful |
03 |
I need some help but manage most of my personal care |
04 |
I need help every day in most aspects of self-care |
05 |
I do not get dressed, I wash with difficulty and stay in bed |
06 |
|
|
Lifting |
|
I can lift heavy weights without extra pain |
01 |
I can lift heavy weights but it gives extra pain |
02 |
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently placed eg. on a table |
03 |
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned |
04 |
I can lift very light weights |
05 |
I cannot lift or carry anything at all |
06 |
|
|
Walking |
|
Pain does not prevent me walking any distance |
01 |
Pain prevents me from walking more than 1 mile |
02 |
Pain prevents me from walking more than 1.5 mile |
03 |
Pain prevents me from walking more than 100 yards |
04 |
I can only walk using a stick or crutches |
05 |
I am in bed most of the time |
06 |
|
|
Sitting |
|
I can sit in any chair as long as I like |
01 |
I can only sit in my favourite chair as long as I like |
02 |
Pain prevents me sitting more than one hour |
03 |
Pain prevents me from sitting more than 30 minutes |
04 |
Pain prevents me from sitting more than 10 minutes |
05 |
Pain prevents me from sitting at all |
06 |
|
|
Standing |
|
I can stand as long as I want without extra pain |
01 |
I can stand as long as I want but it gives me extra pain |
02 |
Pain prevents me from standing for more than 1 hour |
03 |
Pain prevents me from standing for more than 30 minutes |
04 |
Pain prevents me from standing for more than 10 minutes |
05 |
Pain prevents me from standing at all |
06 |
|
|
Sleeping |
|
My sleep is never disturbed by pain |
01 |
My sleep is occasionally disturbed by pain |
02 |
Because of pain I have less than 6 hours sleep |
03 |
Because of pain I have less than 4 hours sleep |
04 |
Because of pain I have less than 2 hours sleep |
05 |
Pain prevents me from sleeping at all |
06 |
|
|
Sex life (if applicable) |
|
My sex life is normal and causes no extra pain |
01 |
My sex life is normal but causes some extra pain |
02 |
My sex life is nearly normal but is very painful |
03 |
My sex life is severely restricted by pain |
04 |
My sex life is nearly absent because of pain |
05 |
Pain prevents any sex life at all |
06 |
|
|
Social life |
|
My social life is normal and gives me no extra pain |
01 |
My social life is normal but increases the degree of pain |
02 |
Pain has no significant effect on my social life apart from limiting my more energetic interests eg, sport |
03 |
Pain has restricted my social life and I do not go out as often |
04 |
Pain has restricted my social life to my home |
05 |
I have no social life because of pain |
06 |
|
|
Travelling |
|
I can travel anywhere without pain |
01 |
I can travel anywhere but it gives me extra pain |
02 |
Pain is bad but I manage journeys over two hours |
03 |
Pain restricts me to journeys of less than one hour |
04 |
Pain restricts me to short necessary journeys under 30 minutes |
05 |
Pain prevents me from travelling except to receive treatment |
06 |