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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