Online Evaluation

The rating scales below are designed to measure the degree to which several aspects of your life are presently disrupted by chronic pain. In other words, we would like to know how much your pain is preventing you from doing what you would normally do, or from doing it as well as you normally would. Respond to each category by indicating the overall impact of pain in your life, not just when the pain is at its worst.

For each of the six categories of daily living listed, Please click the radio button next to the number which best describes your typical level of activities. A score of 0 means no disability at all, and a score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain.


* required fields

Note: All answers below are required to help us make the most accurate assessment of your condition.
Name: First:*

Last:*

Referred by:

E-mail:*
Phone: Day:*

Evening:*

Best number to reach you:* Day Phone

Evening Phone

1. Family/Home Responsibilities: This category refers to activities related to the home or family. It includes chores and duties performed around the house (e.g., yard work) and errands or favors for other family members 9e.g., driving the children to school).

0
Completely able to function
1 2 3 4 5 6 7 8 9 10
Totally unable to function
2. Recreation: This category includes hobbies, sports, and other similar leisure time activities.

0
Completely able to function
1 2 3 4 5 6 7 8 9 10
Totally unable to function
3. Social Activity: This category refers to activities which involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out and other social functions.

0
Completely able to function
1 2 3 4 5 6 7 8 9 10
Totally unable to function
4. Occupation: This category refers to activities that are part of or directly related to one's job. This includes nonpaying jobs as well, such as that of a homemaker or volunteer worker.

0
Completely able to function
1 2 3 4 5 6 7 8 9 10
Totally unable to function
5. Self Care: This category refers to activities which involve personal maintenance and independent daily living (eg, taking a shower, driving, getting dressed, etc.)

0
Completely able to function
1 2 3 4 5 6 7 8 9 10
Totally unable to function
6. Life-Support Activity: This category refers to basic life-supporting behaviors such as eating, sleeping and breathing.

0
Completely able to function
1 2 3 4 5 6 7 8 9 10
Totally unable to function

Additional Comments: (optional)
Pertaining to your condition, i.e. specific injuries which may have caused or contributed to your pain.

Security Code:

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