[%PracticeInfo%]	Pain Disability Questionnaire

Patient name:______________________________  Signature:_____________________________  Date: __________

Instructions: These questions ask your views about how your pain now affects how you function in everyday activities. Please answer every question and mark the ONE number on EACH scale that best describes how you feel.

1. Does your pain interfere with your normal work inside and outside the home?
Work normally	 Unable to work at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
2. Does your pain interfere with personal care (such as washing, dressing, etc.)?
Take care of myself completely 						Need help with all my personal care
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
3. Does your pain interfere with your traveling?
Travel anywhere I like 								Only travel to see doctors
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
4. Does your pain affect your ability to sit or stand?
No problems 										Cannot sit /stand at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things?
No problems 											Cannot do at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat?
No problems 											Cannot do at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
7. Does your pain affect your ability to walk or run?
No problems 											Cannot walk/run at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
8. Has your income declined since your pain began?
No decline 											Lost all income
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
9. Do you have to take pain medication every day to control your pain?
No medication needed						 On pain medication throughout the day
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
10. Does your pain force your to see doctors much more often than before your pain began?
Never see doctors 										See doctors weekly
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
11. Does your pain interfere with your ability to see the people who are important to you as much as you would like?
No problem 											Never see them
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
12. Does your pain interfere with recreational activities and hobbies that are important to you?
No interference 										Total interference
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
13. Do you need the help of your family and friends to complete everyday tasks (including both work outside the home and housework) because of your pain?
Never need help 										Need help all the time
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
14. Do you now feel more depressed, tense, or anxious than before your pain began?
No depression/tension 								Severe depression / tension
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
15. Are there emotional problems caused by your pain that interfere with your family, social and or work activities?
No problems 											Severe problems
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10