Information from this questionnaire helps us understand your problem better, and it especially helps us evaluate the possible long-term consequences your pain may have. It is important that you read each question carefully and answer it as best you can. There are no right or wrong answers. Please answer every question. If you have difficulty, select the answer that best describes your situation.

These questions and statements apply if you have aches or pains, such as back, shoulder or neck pain. Please read and answer questions carefully. Do not take long to answer the questions, however it isimportant that you answer every question. There is always a response for your particular situation.

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

Here is a list of five activities. Select the one number that best describes your current ability to participate in each of these activities.

Please read each statement and mark a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

Rating

0 = Did not apply to me at all, 1 = Applied to me to some degree, or some of the time, 2 = Applied to me to a considerable degree, or a good part of time, 3 = Applied to me very much, or most of the time 

Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery.

Instructions: We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the following scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain. 

Rating;

0 = Not at all, 1 = To a slight degree, 2 = To a moderate degree, 3 = To a great degree, 4 = All the time

Please rate how confident you are that you can do the following things at present, despite the pain. To indicate your answer, mark one of the numbers for each item, where 0 = not at all confident and 6 = completely confident.

Remember this questionnaire is not asking whether or not you have been doing these things, but rather how confident you are that you can do them at present, despite the pain.