Outcome Measure. Date * - note that month comes first MM DD YYYY Name * First Name Last Name NUMERICAL PAIN RATING SCALE * Please select your average pain in the last 24 hours on a scale of 0 - 10, where 0 equals no pain and 10 equals the worst imaginable pain. 0 = no pain 1 2 3 4 5 6 7 8 9 10 = worst possible pain GLOBAL RATING OF CHANGE * Please select how you would describe yourself now with respect to your injury, compared to immediately after your accident? -5 = very much worse -4 -3 -2 -1 0 = unchanged 1 2 3 4 5 = completely recovered THE QUEBEC BACK PAIN DISABILITY SCALE Please rate your ability to do the following activities as of today by selecting the number beside the appropriate response. Please answer all questions. Please choose one response for each activity. 1. Get out of bed? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 2. Sleep through the night? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 3. Turn over in bed? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 4. Ride in a car? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 5. Stand up for 20-30 minutes? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 6. Sit in a chair for several hours? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 7. Climb one flight of stairs? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 8. Walk a few blocks? (300-400m) * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 9. Walk several kilometres? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 10. Reach up to high shelves? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 11. Throw a ball? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 12. Run one block? (about 100m) * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 13. Take food out of the refrigerator? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 14. Make your bed? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 15. Put on socks or pantyhose? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 16. Bend over to clean the bathtub? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 17. Move a chair? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 18. Pull or push heavy doors? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 19. Carry two bags of groceries? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do 20. Lift & carry a heavy suitcase? * 0 = No difficulty 1 = Minimally difficult 2 = Somewhat difficult 3 = Fairly difficult 4 = Very difficult 5 = Unable to do GOAL SETTING Please write a functional goal relating to an everyday work, home or sporting activity that you hope to achieve during the course of treatment for your injury. Thank you! No pressure, no fuss, nice and easy, and paper-free.
