PLEASE MAKE AN “X” ALONG THE LINE TO SHOW by zqc90133

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									PLEASE MAKE AN “X” ALONG THE LINE TO SHOW H0W FAR FROM NORMAL
TOWARD THE WORST POSSIBLE SITUATION YOUR PAIN PROBLEM HAS
TAKEN YOU DURING THE PAST WEEK:

1. How bad is your pain?
No pain                                                                          Worst possible

2. How bad is the pain at night?
No pain                                                                          Worst possible

3. Does the pain interfere with your lifestyle?
No problem                                                              Total change in lifestyle

4. How good are pain killers for your pain?
Complete relief                                                                         No relief

5. How stiff is your injured area?
No stiffness                                                           Worst possible stiffeness

6. Does your pain interfere with walking?
No problem                                                                          Cannot walk

7. Do you hurt when walking?
No pain                                                                       Worst possible pain

8. Does your pain keep you from standing still?
Can stand still as long as I want                                              Cannot stand at all

9. Does your pain keep you from twisting?
No problem                                                                           Cannot twist

10. Does your pain allow you to sit in an upright hard chair?
Sit as long as I like                                                        Cannot use hard chair

11. Does your pain allow you to sit in a soft chair?
Sit as long as I like                                                        Cannot use soft chair

12. Does your injured body part hurt when lying in bed?
No pain                                                                            No relief at all

13. How much does your pain limit your normal lifestyle?
No limit                                                                      Cannot do anything

14. Does your pain interfere with your activities of daily living or work?
No problem                                                                         Major problem

15. How much have you had to change your home/workplace activities because of pain?
No change                                                                 A great deal of change

NAME________________________________________   DATE_________________
SCORING:
Each question is worth 10 points. Make hash lines in each horizontal line for a total of 6 lines, including the ones on
the ends. You will end up with 5 equal sized segments in between the ends, and each hash mark is graded 0-5. The
total high score is 150, the low is 0

The questionnaire was adapted from an article in Spine Journal, May 2003, titled The Million Visual Analog Scale. In
this study, they determined that a score of zero was zero, scoring between 1-40 was mild, 41-70 was moderate, 71-100
was severe, 101-130 was very severe, and 131-150 was extreme.

								
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