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.
  • Name*full name
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  • Email*a valid email address
    1
  • 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.
    2
  • Section 1 – Pain intensity*select one
    I have no pain at the moment
    The pain is very mild at the moment
    The pain is moderate at the moment
    The pain is fairly severe at the moment
    The pain is very severe at the moment
    The pain is the worst imaginable at the moment
    3
  • Section 2 – Personal care (washing, dressing etc)*select one
    I can look after myself normally without causing extra pain
    I can look after myself normally but it causes extra pain
    It is painful to look after myself and I am slow and careful
    I need some help but manage most of my personal care
    I need some help but manage most of my personal care
    I do not get dressed, I wash with difficulty and stay in bed
    4
  • Section 3 – Lifting*select one
    I can lift heavy weights without extra pain
    I can lift heavy weights but it gives extra pain
    Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently placed eg. on a table
    Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned
    Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned
    I can lift very light weights
    I cannot lift or carry anything at all
    5
  • Section 4 – Walking*select one
    Pain does not prevent me walking any distance
    Pain prevents me from walking more than 2 kilometres
    Pain prevents me from walking more than 1 kilometre
    Pain prevents me from walking more than 500 metres
    I can only walk using a stick or crutches
    I am in bed most of the time
    6
  • Section 5 – Sitting*select one
    I can sit in any chair as long as I like
    I can only sit in my favourite chair as long as I like
    Pain prevents me sitting more than one hour
    Pain prevents me from sitting more than 30 minutes
    Pain prevents me from sitting more than 10 minutes
    Pain prevents me from sitting at all
    7
  • Section 6 – Standing*select one or more
    I can stand as long as I want without extra pain
    I can stand as long as I want but it gives me extra pain
    Pain prevents me from standing for more than 1 hour
    Pain prevents me from standing for more than 3 minutes
    Pain prevents me from standing for more than 10 minutes
    Pain prevents me from standing at all
    8
  • Section 7 – Sleeping*select one
    My sleep is never disturbed by pain
    My sleep is occasionally disturbed by pain
    Because of pain I have less than 6 hours sleep
    Because of pain I have less than 4 hours sleep
    Because of pain I have less than 2 hours sleep
    Pain prevents me from sleeping at all
    9
  • Section 8 – Sex life (if applicable)*select one
    My sex life is normal and causes no extra pain
    My sex life is normal but causes some extra pain
    My sex life is nearly normal but is very painful
    My sex life is severely restricted by pain
    My sex life is nearly absent because of pain
    Pain prevents any sex life at all
    10
  • Section 9 – Social life*select one or more
    My social life is normal and gives me no extra pain
    My social life is normal but increases the degree of pain
    Pain has no significant effect on my social life apart from limiting my more energetic interests eg, sport
    Pain has restricted my social life and I do not go out as often
    Pain has restricted my social life to my home
    I have no social life because of pain
    11
  • Section 10 – Travelling*select one
    I can travel anywhere without pain
    I can travel anywhere but it gives me extra pain
    Pain is bad but I manage journeys over two hours
    Pain restricts me to journeys of less than one hour
    Pain restricts me to short necessary journeys under 30 minutes
    Pain prevents me from travelling except to receive treatment
    12
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