These questions and statements apply if you have aches or pains, such as back, shoulder or neck pain.
  • Name*full name
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  • Email*a valid email address
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  • Please read and answer questions carefully. Do not take too long to answer the questions, however it is important that you answer every question. There is always a response for your particular situation.
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  • 1. Where do you have pain? Place a tick for all appropriate sites.*select one or more
    Neck
    Shoulder
    Arm
    Lower back
    Leg
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  • Other (state)*
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  • 2. How many days of work have you missed because of pain during the last 18 months?*select one
    0 days (1)
    1-2 days (2)
    3-7 days (3)
    15-30 days (5)
    1 month (6)
    2 months (7)
    3-6 months (8)
    6-12 months (9)
    over 1 year (10)
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  • 3. How long have you had your current pain problem?*select One
    0-1 weeks (1)
    1-2 days (2)
    3-7 days (3)
    8-14 days (4)
    15-30 days (5)
    1 month (6)
    2 months (7)
    3-6 months (8)
    6-9 months (8)
    9-12 months (9)
    over 1 year (10)
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  • 4. Is your work heavy or monotonous?*Use the slider to choose.
    Not at all > Extremely00 - 00
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  • 5. How would you rate the pain that you have had during the past week?*Use the slider to choose.
    No pain > Pain as bad as it could be00 - 00
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  • 6. In the past three months, on average, how bad was your pain? Circle one.*Use the slider to choose.
    No pain > Pain as bad as it could be00 - 00
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  • 7. How often would you say that you have experienced pain episodes, on average, during the past three months?*Use the slider to choose.
    Never > 10.Always00 - 00
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  • 8. Based on all things you do to cope or deal with your pain, on an average day, how much are you able to decrease it?*Use the slider to choose.
    Can’t decrease it at all > Can decrease it completely00 - 00
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  • 9. How tense or anxious have you felt in the past week?*Use the slider to choose.
    Absolutely calm and relaxed > As tense and anxious as I’ve ever felt00 - 00
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  • 10. How much have you been bothered by feeling depressed in the past week?*Use the slider to choose.
    Not at all > Extremely00 - 00
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  • 11. In your view, how large is the risk that your current pain may become persistent?*Use the slider to choose.
    No risk > Very large rish00 - 00
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  • 12. In your estimation, what are the chances that you will be able to work in six months?*Use the slider to choose.
    No chance > Very large chance00 - 00
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  • 13. If you take into consideration your work routines, management, salary, promotion possibilities and work mates, how satisfied are you with your job?*Use the slider to choose.
    Not satisfied at all > Very satisfied00 - 00
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  • Here are some of the things that other people have told us about their pain. For each statement, use the slider to choose from 0 to 10 to say how much physical activities, such as bending, lifting, walking or driving, would affect your pain. Completely disagree > Agree*
    14. Physical activity makes my pain worse.00 - 00
    15. An increase in pain is an indication that I should stop what I’m doing until the pain decreases.00 - 00
    16. I should not do my normal work with my present pain.00 - 00
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  • Here is a list of five activities. Choose the slider to choose what best describes your current ability to participate in each of these activities. Can’t do it because of pain problem > Can do it without pain being a problem*
    17. I can do light work for an hour.00 - 00
    18. I can walk for an hour.00 - 00
    19. I can do ordinary household chores.00 - 00
    20. I can do the weekly shopping.00 - 00
    21. I can sleep at night.00 - 00
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  • 19
  • Hobbies*select one or more
    Option A
    Option B
    Option C
    Option D
    Option E
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