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Pain Intensity * (0) - I can tolerate the pain I have without having to use pain medication. (0) - I can tolerate the pain I have without having to use pain medication. (1) - The pain is bad, but I can manage without having to take pain medication. (2) - Pain medication provides me with complete relief from pain. (3) - Pain medication provides me with moderate relief from pain. (4) - Pain medication provides me with little relief from pain. (5) - Pain medication has no effect on my pain.
Personal Care (washing, dressing, etc.) * (0) - I can take care of myself normally without causing increased pain. (0) - I can take care of myself normally without causing increased pain. (1) - I can take care of myself normally, but it increases my pain. (2) - It is painful to take care of myself, and I am slow and careful. (3) - I need help, but I am able to manage most of my personal care. (4) - I need help every day in most aspects of my care. (5) - I do not get dressed, wash with difficulty, and stay in bed.
Lifting * (0) - Pain does not prevent me from walking any distance. (0) - Pain does not prevent me from walking any distance. (1) - Pain prevents me from walking more than 1 mile. (2) - Pain prevents me from walking more than 1⁄2 mile. (3) - Pain prevents me from walking more than 1⁄4 mile. (4) - I can only walk with crutches or a cane. (5) - I am in bed most of the time and have to crawl to the toilet.
Sitting * (0) - I can sit in any chair as long as I like. (0) - I can sit in any chair as long as I like. (1) - I can only sit in my favorite chair as long as I like. (2) - Pain prevents me from sitting more than 1 hour. (3) - Pain prevents me from sitting more than 1⁄2 hour. (4) - Pain prevents me from sitting more than 10 minutes. (5) - Pain prevents me from sitting at all.
Standing * (0) - I can stand as long as I want without increased pain. (0) - I can stand as long as I want without increased pain. (1) - I can stand as long as I want but, it increases my pain. (2) - Pain prevents me from standing more than 1 hour. (3) - Pain prevents me from standing more than 1/2 hour. (4) - Pain prevents me from standing more than 10 minutes. (5) - Pain prevents me from standing at all.
Sleeping * (0) - Pain does not prevent me from sleeping well. (0) - Pain does not prevent me from sleeping well. (1) - I can sleep well only by using pain medication. (2) - Even when I take pain medication, I sleep less than 6 hours. (3) - Even when I take pain medication, I sleep less than 4 hours. (4) - Even when I take pain medication, I sleep less than 2 hour. (5) - Pain prevents me from sleeping at all.
Social Life * (0) - My social life is normal and does not increase my pain. (0) - My social life is normal and does not increase my pain. (1) - My social life is normal, but it increases my level of pain. (2) - Pain prevents me from participating in more energetic activities (eg. sports, dancing). (3) - Pain prevents me from going out very often. (4) - Pain has restricted my social life to my home. (5) - I have hardly any social life because of my pain.
Traveling * (0) - I can travel anywhere without increased pain.. (0) - I can travel anywhere without increased pain.. (1) - I can travel anywhere, but it increases my pain. (2) - My pain restricts my travel over 2 hours. (3) - My pain restricts my travel over 1 hour. (4) - My pain restricts my travel to short necessary journeys journeys under 1/2 hour. (5) - My pain prevents all travel except for visits to the physician/therapist or hospital.
Employment/Homemaking * (0) - My normal homemaking/job activities do not cause pain. (0) - My normal homemaking/job activities do not cause pain. (1) - My normal homemaking/job activities increase my pain, but I can still perform all that is required of me. (2) - I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (eg, lifting, vacuuming). (3) - Pain prevents me from doing anything but light duties. (4) - Pain prevents me from doing even light duties. (5) - Pain prevents me from performing any job or homemaking chores.
