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Pain Outcomes Questionnaire

INSTRUCTIONS:
Please circle the number that best describes the question being asked. Choose only 1 number per question.

1) On a scale of 0 to 10, with 0 being no pain at all and 10 being the worst possible pain,
how would you rate your pain on average during the past week?
←                                                                                                                                             →
No Pain           0          1           2          3          4           5         6        7        8       9      10       Worst Possible Pain

2) Does your pain interfere with your ability to walk?
←                                                                                                                                        →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

3) Does your pain interfere with your ability to carry/handle everyday objects such as a
bag of groceries or books?
←                                                                                                                                       →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

4) Does your pain interfere with your ability to climb stairs?
←                                                                                                                                        →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

5) Does your pain require you to use a cane, walker, wheelchair, or other devices?
←                                                                                                                                       →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

6) Does your pain interfere with your ability to bathe yourself?
←                                                                                                                                        →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

7) Does your pain interfere with your ability to dress yourself?
←                                                                                                                                         →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

8) Does your pain interfere with your ability to use the bathroom?
←                                                                                                                                         →
Not at all          0          1           2          3          4           5         6       7        8       9      10       All the time

9) Does your pain interfere with your ability to manage your personal grooming (for
example, combing your hair, brushing your teeth, etc.)?
←                                                                                                                                        →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

10) Does your pain affect your self-esteem or self-worth?
←                                                                                                                                       →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

11) How would you rate your physical activity?
←                                                                                                                                        →
Significant       0          1           2          3          4           5         6.        7        8       9      10          Can perform
limitation									                                    vigorous activities
in basic									                                      without limitation
activities

12) How would you rate your overall energy?
←                                                                                                                     →
Totally worn out   0          1           2          3          4           5         6        7        8       9      10       Most energy ever

13) How would you rate your strength and endurance today?
←                                                                                                   →
Very poor      0          1           2          3          4           5          6        7         8         9         10      Very high

14) How would you rate your feelings of depression today?
←                                                                                                                       →
Not at all          0          1           2          3          4           5         6        7        8       9      10      Extremely depressed
depressed

15) How would you rate your feelings of anxiety today?
←                                                                                                                     →
Not at all          0          1           2          3          4           5         6        7        8       9      10      Extremely anxious
anxious

16) How much do you worry about re-injuring yourself if you are more active?
←                                                                                                               →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

17) How safe do you think it is for you to exercise?
←                                                                                                               →
Not safe at all          0          1           2          3          4           5         6        7        8       9      10       Extremely safe

18) Do you have problems concentrating on things today?
←                                                                                                               →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

19) How often do you feel tense?
←                                                                                                               →
Not at all          0          1           2          3          4           5         6        7        8       9      10       All the time

Source: Michael E. Clark, Ph.D. and Ronald J. Gironda, Ph.D.