1. Over the past few days, on average, how would you rate your pain on a scale where '0' is 'no pain' and '10' is 'worst pain possible'?*

2. Over the past few days, on average, how has your complaint interfered with your daily activities (housework, washing, dressing, lifting, walking, reading, driving, climbing stairs, getting in/out of bed/chair, sleeping) on a scale where ‘0’ is ‘no interference’ and ’10’ is ‘completely unable to carry on with normal daily activities’?*

3. Over the past few days, on average, how much has your painful complaint interfered with your normal social routine including recreational, social and family activities, on a scale where ‘0’ is ‘no interference’ and ’10’ is ‘completely unable to participate in any social and recreational activity’?*

4. Over the past few days, on average, how anxious (uptight, tense, irritable, difficulty in relaxing/concentrating) have you been feeling, on a scale where ‘0’ is ‘not at all anxious’ and ’10’ is ‘ extremely anxious’?*

5. Over the past few days, on average, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, lethargic) have you been feeling, on a scale where ‘0’ is ‘not at all depressed’ and ’10’ is ‘ extremely depressed’?*

6. Over the past few days, how do you think your work (both inside the home and/or employed work) have affected your painful complaint, on a scale where ‘0’ is ‘make it no worse’ and ’10’ is ‘make it very much worse’?*

7. Over the past few days, on average, how much have you been able to control (help/reduce) and cope with your pain on your own, on a scale where ‘0’ is ‘I can control it completely’ and ’10’ is ‘I have no control whatsoever’?*

Put a CROSS in ONE box for EACH of the following statements that best describes your painful complaint and how it is affecting you NOW. Please read each question carefully before answering.

Thank you very much for your time in completing this questionnaire

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