Pain Screening Questionnaire

Fill out and submit the following questionnaire so that we can better understand and evaluate your present condition and situation.

Please ensure that you have answered all the questions.


1. How long have you had your current pain problem?
0-1 weeks
1-2 weeks
3-4 weeks
4-5 weeks
6-8 weeks
9-11 weeks
3-6 months
6-9 months
9-12 months
over 1 year
2. How would you rate the pain level that you have had during the past week?
0 1 2 3 4 5 6 7 8 9 10

No pain = 0      Most severe = 10

For questions 3 and 4, please select the number that best describes your current ability to participate in each of these activities.

3. I can do light work (or home duties) for an hour.
0 1 2 3 4 5 6 7 8 9 10

Not at all = 0      Without any difficulty = 10

4. I can sleep at night.
0 1 2 3 4 5 6 7 8 9 10

Not at all = 0      Without any difficulty = 10

5. How tense or anxious have you felt in the past week?
0 1 2 3 4 5 6 7 8 9 10

Calm & relaxed = 0      Extremely tense & anxious = 10

6. How much have you been bothered by feeling depressed in the past week?
0 1 2 3 4 5 6 7 8 9 10

Not at all = 0      Extremely = 10

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 = 0      Very large risk = 10

8. In your estimation, what are the chances you will be working your normal duties (at home or work) in 3 months?
0 1 2 3 4 5 6 7 8 9 10

No chance = 0      Very large chance = 10

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 = 0      Completely agree = 10

10. I should not do my normal work (at work or home duties) with my present pain.
0 1 2 3 4 5 6 7 8 9 10

Completely disagree = 0      Completely agree = 10