Questionnaire for Grading Severity of Chronic Pain

Do you have a physical condition which has caused sufficient pain in the past to affect the quality of your life?

About how many days in the past 6 months have you been kept from your usual activities because of your pain ?

How would you rate your pain on a 0-10 scale at the present time (right now)?

During the past 6 months, how intense was your worst pain?

During the past 6 months, on the average, how intense was your pain?

In the past 6 months, how much has the pain interfered with your daily activities?

In the past 6 months, how much has the pain changed your ability to take part in recreational, social and family activities?

In the past 6 months, how much has the pain changed your ability to work (including housework)?