*Patient Name:

*Date of Birth:

Please select the one best answer for your abilities at this time:

Over the last week were you able to:

Dress yourself, including tying shoelaces and doing buttons? 

Get in and out of Bed? 

Lift a full cup or glass to your mouth? 

Walk outdoors on flat ground? 

Wash and dry your entire body? 

Bend down to pick up clothing from the floor? 

Turn regular faucets on and off? 

Get in and out of a car, bus, train or airplane? 

Walk two miles or three kilometers, if you wish? 

Participate in recreational activities and sports as you would like, if you wish? 

Get a good night's sleep? 

Deal with feeling of anxiety or being nervous? 

How much pain have you ha because of your condition OVER THE PAST WEEK? (0 = no pain, 10 = vpain as bad as it could be)
Please indicate how severe your pain has been: 

Considering all the ways in which illness and health conditions may affect you at this time please indicate how you are doing (0 = very well, 10 = very poorly)