| 1. What year were you born?:
19____ |
2. Are you:
male female |
3. Were you born in New Zealand?
yes no |
4. Where do you have pain? Place
a tick ( ))
for all the appropriate sites.
neck
shoulders upper back
lower back leg |
5. How many days of work have you
missed because of pain during the past 18 months? Tick ()
one.
| 0 days
[1] |
1-2 days [2] |
3-7 days [3] |
8-14 days [4] |
15-30 days [5] |
| 1 month
[6] |
2 months [7] |
3-6 months [8] |
6-12 months [9] |
over 1 year [10] |
|
6. How long have you had your
current pain problem? Tick ()
one.
| 0-1 weeks [1]
|
1-2 weeks [2] |
3-4 weeks [3] |
4-5 weeks [4] |
6-8 weeks [5] |
| 9-11 weeks [6]
|
3-6 months [7] |
6-9 months [8] |
9-12 months [9] |
over 1 year [10] |
|
7. Is your work heavy or
monotonous? Circle the best alternative.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Not at all |
|
|
|
|
|
|
|
|
|
Extremely |
|
8. How would you rate the pain
that you have had during the past week? Circle one.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| No
pain |
|
|
|
|
|
|
|
|
|
Pain as bad
as
it could be |
|
9. In the past three months, on
average, how bad was your pain? Circle one.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| No
pain |
|
|
|
|
|
|
|
|
|
Pain as bad
as
it could be |
|
10. How often would you say that
you have experienced pain episodes, on average, during the past 3
months? Circle one.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Never |
|
|
|
|
|
|
|
|
|
Always |
|
11. Based on all the things you
do to cope, or deal with your pain, on an average day, how much are
you able to decrease it? Circle one.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Can't
decrease it at all |
|
|
|
|
|
|
|
|
|
Can decrease
it
completely |
|
12. How tense or anxious have you
felt in the past week? Circle one.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
Absolutely
calm
and relaxed |
|
|
|
|
|
|
|
|
|
As tense and
anxious
as I've ever felt |
|
13. How much have you been
bothered by feeling depressed in the past week? Circle one.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Not
at all |
|
|
|
|
|
|
|
|
|
Extremely |
|
14. In your view, how large is
the risk that your current pain may become persistent? Circle one.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| No
risk |
|
|
|
|
|
|
|
|
|
Very large risk |
|
15. In your estimation, what are
the chances that you will be working in 6 months? Circle one.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| No
chance |
|
|
|
|
|
|
|
|
|
Very large
chance |
|
16. If you take into
consideration your work routines, management, salary, promotion
possibilities and work mates, how satisfied are you with your job?
Circle one.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Not
at all satisfied |
|
|
|
|
|
|
|
|
|
Completely
satisfied |
|
| Here are some of the things which
other people have told us about their back pain. For each statement
please circle one number from 0 to 10 to say how much physical
activities, such as bending, lifting, walking or driving would
affect your back. |
17. Physical activity makes my
pain worse
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Completely
disagree |
|
|
|
|
|
|
|
|
|
Completely
agree |
|
18. An increase in pain is an
indication that I should stop what I am doing until the pain
decreases.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Completely
disagree |
|
|
|
|
|
|
|
|
|
Completely
agree |
|
19. I should not do my normal
work with my present pain.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Completely
disagree |
|
|
|
|
|
|
|
|
|
Completely
agree |
|
| Here is a list of 5 activities.
Please circle the one number which best describes your current
ability to participate in each of these activities. |
20. I can do light work for an
hour.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Can't
do it because of pain problem |
|
|
|
|
|
|
|
|
|
Can do
it
without pain
being a problem |
|
21. I can walk for an hour.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Can't
do it because of pain problem |
|
|
|
|
|
|
|
|
|
Can do
it
without pain
being a problem |
|
22. I can do ordinary household
chores.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Can't
do it because of pain problem |
|
|
|
|
|
|
|
|
|
Can do
it
without pain
being a problem |
|
23. I can go shopping.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Can't
do it because of pain problem |
|
|
|
|
|
|
|
|
|
Can do
it
without pain
being a problem |
|
24. I can sleep at night.
| 0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Can't
do it because of pain problem |
|
|
|
|
|
|
|
|
|
Can do
it
without pain
being a problem |
|
