know your health status

Mark the appropriate answer on the basis of your Appetite

Note– The marked option is your score for each question and finally sums up all the marks. If score is

≥ (Equal to or More than) 28 then it indicates at least 5% weight loss within 6 months

My appetite is Score
very poor 01
poor 02
average 03
good 04
very good 05
When I eat
I feel full after eating only a few mouthfuls 01
I feel full after eating about a third of a meal 02
I feel full after eating over half a meal 03
I feel full after eating most of the meal 04
I hardly ever feel full 05
I feel hungry
rarely 01
occasionally 02
some of the time 03
most of the time 04
all of the time 05
Food tastes
very bad 01
bad 02
average 03
good 04
very good 05
Compared to when I was younger, food tastes
much worse 01
worse 02
just as good 03
better 04
much better 05
Normally I eat
less than one meal a day 01
one meal a day 02
two meals a day 03
three meals a day 04
more than three meals a day 05
I feel sick or nauseated when I eat
most times 01
often 02
sometimes 03
rarely 04
never 05
Most of the time my mood is
very sad 01
sad 02
neither sad nor happy 03
happy 04
very happy 05

(Downloaded from ajcn.nutrition.org at PENNSYLVANIA STATE UNIV PATERNO LIBRARY on March 6, 2016 and American Journal of Nutrition)

Instructions

This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by checking ONE box in each section for the statement which best applies to you. We realise you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem.

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

Scoring instructions

For each section the total possible score is 5: if the first statement is marked the section score = 0; if the last statement is marked, it = 5. If all 10 sections are completed the score is calculated as follows: Example: 16 (total scored) 50 (total possible score) x 100 = 32% If one section is missed or not applicable the score is calculated: 16 (total scored) 45 (total possible score) x 100 = 35.5% Minimum detectable change (90% confidence): 10% points (change of less than this may be attributable to error in the measurement).

Interpretation of scores

0% to 20%: minimal disability The patient can cope with most living activities. Usually no treatment is indicated apart from advice on lifting sitting and exercise
21%-40%: moderate disability The patient experiences more pain and difficulty with sitting, lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care, sexual activity and sleeping are not grossly affected and the patient can usually be managed by conservative means
41%-60%: severe disability Pain remains the main problem in this group but activities of daily living are affected. These patients require a detailed investigation
61%-80%: crippled Back pain impinges on all aspects of the patient’s life. Positive intervention is required
81%-100% These patients are either bed-bound or exaggerating their symptoms

(References 1. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine 2000 Nov 15;25(22):2940-52; discussion 52).

This questionnaire is to assess your sleep quality. Respond appropriate answer thinking about sleep during last complete one month.

How long does it take you to fall asleep? Score
0–15 min. 4
b. 16–30 min. 3
31–45 min. 2
46–60 min. 1
>60 min. 0
If you then wake up one or more times during the night, how long are you awake in total?
(Add up all the time you are awake.)
0–15 min. 4
16–30 min. 3
31–45 min. 2
46–60 min. 1
>60 min. 0
If your final wake-up time occurs before you intend to wake up, how much earlier is this?
I don’t wake up too early/Up to 15 min. early 4
16–30 min. early 3
31–45 min. early 2
46–60 min. early 1
>60 min. early 0
How many nights a week do you have a problem with your sleep?
0–1 4
2 3
3 2
4 1
5–7 0
How would you rate your sleep quality?
Very good 4
Good 3
Average 2
Poor 1
Very poor 0
Thinking about the past month, to what extent has poor sleep
affected your mood, energy, or relationships?
Not at all 4
A little 3
Somewhat 2
Much 1
Very much 0
affected your concentration, productivity, or ability to stay awake?
Not at all 4
A little 3
Somewhat 2
Much 1
Very much 0
troubled you in general?
Not at all 4
A little 3
Somewhat 2
Much 1
Very much 0
How long have you had a problem with your sleep?
I don’t have a problem /<1 month 4
1–2 months 3
3–6 months 2
7–12 months 1
>1 year 0

Now add up your total score by using the following score chart:

0–9 Your sleep problems seem to be severe. You should definitely try to get some help.

10–18 You have some sleep problems. It’s important to examine your sleep habits and see how you can make changes.

19–27 Your sleep is in good shape, but there are still many steps you can take to make it even better.

28–36 Your sleep is in great shape. Keep doing what you’re doing and spread the word!

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