2. How would you rate the pain that you have had during the past week? Circle one.

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• No pain
• Pain as bad as it could be

Please circle the one number which best describes your current ability to participate in each of these activities.

3. I can do light work for an hour.

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• Can’t do it because
  of the pain problem
• Can do it without pain
  being a problem

10-x

4. I can sleep at night.

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• Can't do it because
  of the pain problem
• Can do it without pain
  being a problem

10-x

5. How tense or anxious have you felt in the past week? Circle one.

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• Absolutely calm and relaxed
• As tense and anxious as I’ve ever felt

6. How much have you been bothered by feeling depressed in the past week? Circle one.

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• Not at all
• Extremely

7. In your view, how large is the risk that your current pain may become persistent?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• No risk
• Very large risk

8. In your estimation, what are the chances you will be working your normal duties in 3 months

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• No chance
• Very Large Chance

10-x

Here are some of the things which other people have told us about their pain. For each statement please circle one number from 0-10 to say how much physical activities, such as bending, lifting, walking, or driving affect your pain.

9. An increase in pain is an indication that I should stop what I’m doing until the pain decreases.

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• Completely disagree
• Completely agree

10. I should not do my normal work with my present pain.

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• Completely disagree
• Completely agree