Name *

First Name

Last Name

1. Pain Intensity *

(0) I have no pain at the moment.

(1) The pain is very mild at the moment.

(2) The pain is moderate at the moment.

(3) The pain is fairly severe at the moment.

(4) The pain is very severe at the moment.

(5) The pain is the worse imaginable at the moment.

2. Personal Care (washing, dressing, etc) *

(0) I can look after myself normally without extra pain.

(1) I can look after myself normally but it causes extra pain.

(2) It is painful to look after myself and I am slow and careful.

(3) I need some help but manage most of my personal care.

(4) I need help every day in most aspects of self care.

(5) I cannot get dressed, wash with difficulty and stay in bed.

3. Lifting *

(0) I can lift heavy weights without extra pain.

(1) I can lift heavy weights but it gives me extra pain.

(2) Pain prevents me from lifting heavy weights off the floor but I can manage if they are on a table.

(3) Pain prevents me from lifting heavy weights off the floor but I can manage if they are on a table.

(4) I can lift only very light weights.

(5) I cannot lift or carry anything at all.

4. Headache *

(0) I have no headaches at all.

(1) I have slight headaches which come infrequently.

(2) I have moderate headaches which come infrequently.

(3) I have moderate headaches which come frequently.

(4) I have severe headaches which come infrequently.

(5) I have headaches almost all the time.

5. Recreation *

(0) I am able to engage in all my recreational activities without pain.

(1) I am able to engage in my recreational activities with some pain.

(2) I am able to engage in most but not all of my usual recreation activities because of my neck pain.

(3) I am able to engage in a few of my usual recreational activities with some neck pain.

(4) I can hardly do any recreational activities because of neck pain.

(5) I can't do any recreational activities at all.

6. Reading *

(0) I can read as much as I want with no pain in my neck.

(1) I can read as much as I want with slight neck pain.

(2) I can read as much as I want with moderate neck pain.

(3) I can't read as much as I want because of moderate neck pain.

(4) I can hardly read at all because of moderate neck pain.

(5) I cannot read at all because of neck pain.

7. Work *

(0) I can do as much as I want to.

(1) I can only do my usual work but no more.

(2) I can do most of my usual work but no more.

(3) I cannot do my usual work but no more.

(4) I cannot do my usual work.

(5) I can't do any work at all.

8. Sleeping *

(0) Pain does not prevent me from sleeping well.

(1) My sleep is slightly disturbed (<1 hr sleep loss).

(2) My sleep is midly disturbed (1-2 hr sleep loss).

(3) My sleep is moderately disturbed (2-3 hr sleep loss).

(4) My sleep is greatly disturbed (3-4 hr sleep loss).

(5) My sleep is completely disturbed (5-7 hr sleep loss).

9. Concentration *

(0) I can concentrate fully when I want with no difficulty.

(1) I can concentrate fully when I want with slight difficulty.

(2) I have a fair degree of difficulty concentrating when I want.

(3) I have a lot of difficulty concentrating when I want.

(4) I have great difficulty concentrating when I want.

(5) I cannot concentrate at all.

10. Driving *

(0) I can drive my car without nect pain.

(1) I can drive my car as long as I want with slight neck pain.

(2) I can drive my car as long as I want with moderate neck pain.

(3) I can't drive my car as long as I want because of moderate neck pain.

(4) I can hardly drive my car at all because of severe neck pain.

(5) I can't drive my car at all.