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Pain Disability Questionnaire
These questions ask your views about how your pain now affects how you function in everyday activities. Please answer every question and mark the number on each scale that best describes how you feel.
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Name
*
1st name and initial
Your answer
1. Does your pain interfere with your normal work inside and outside the home?
*
Work normally
0
1
2
3
4
5
6
7
8
9
10
Unable to work at all
2. Does your pain interfere with personal care (such as washing, dressing, etc.)?
*
Take care of myself completely
0
1
2
3
4
5
6
7
8
9
10
Need help with all my personal care
3. Does your pain interfere with your traveling?
*
Travel anywhere I like
0
1
2
3
4
5
6
7
8
9
10
Only travel to see doctors
4. Does your pain affect your ability to sit or stand?
*
No problems
0
1
2
3
4
5
6
7
8
9
10
Can not sit/stand at all
5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things?
*
No problems
0
1
2
3
4
5
6
7
8
9
10
Can not do at all
6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat?
*
No problems
0
1
2
3
4
5
6
7
8
9
10
Can not do at all
7. Does your pain affect your ability to walk or run?
*
No problems
0
1
2
3
4
5
6
7
8
9
10
Can not walk/run at all
8. Has your income declined since your pain began?
*
No decline
0
1
2
3
4
5
6
7
8
9
10
Lost all income
9. Do you have to take pain medication every day to control your pain?
*
No medication needed
0
1
2
3
4
5
6
7
8
9
10
On pain medication throughout the day
10. Does your pain force your to see doctors much more often than before your pain began?
*
Never see doctors
0
1
2
3
4
5
6
7
8
9
10
See doctors weekly
11. Does your pain interfere with your ability to see the people who are important to you as much as you would like?
*
No problem
0
1
2
3
4
5
6
7
8
9
10
Never see them
12. Does your pain interfere with recreational activities and hobbies that are important to you?
*
No decline
0
1
2
3
4
5
6
7
8
9
10
Total interference
13. Do you need the help of your family and friends to complete everyday tasks (including both work outside the home and housework) because of your pain?
*
Never need help
0
1
2
3
4
5
6
7
8
9
10
Need help all the time
14. Do you now feel more depressed, tense, or anxious than before your pain began?
*
No depression/ tension
0
1
2
3
4
5
6
7
8
9
10
Severe depression/ tension
15. Are there emotional problems caused by your pain that interfere with your family, social and or work activities?
*
No problems
0
1
2
3
4
5
6
7
8
9
10
Severe problems
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