Outcome Measures Questionnaires

Thank you for taking the time to carefully complete each section below and submitting your responses

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DD slash MM slash YYYY
Name*
Treatment phase that this questionaire refers to*

The Brief Pain Inventory (BPI)

Intensity

Please rate your pain by circling the one number that best describes your pain at its worst in the last 24 hours*
Please rate your pain by circling the one number that best describes your pain at its least in the last 24 hours*
Please rate your pain by circling the one number that best describes your pain on the average*
Please rate your pain by circling the one number that best describes your pain right now*

Interference

General Activity*
Select the one number that describes how, during the past 24 hours, pain has interfered with your
Mood*
Select the one number that describes how, during the past 24 hours, pain has interfered with your
Mobility*
Select the one number that describes how, during the past 24 hours, pain has interfered with your
Work (includes housework and household chores)*
Select the one number that describes how, during the past 24 hours, pain has interfered with your
Relations with other people*
Select the one number that describes how, during the past 24 hours, pain has interfered with your
Sleep*
Select the one number that describes how, during the past 24 hours, pain has interfered with your
Enjoyment of life*
Select the one number that describes how, during the past 24 hours, pain has interfered with your

Pain Self Efficacy Questionnaire (PSEQ)

I can enjoy things despite the pain*
I can do most household chores despite the pain*
I can socialise with my friends or family as often as I used to despite the pain*
I can cope with the pain in most situations*
I can do some form of work despite the pain (paid or unpaid-includes housework)*
I can still do many of the things I enjoy, such as hobbies or leisure activity, despite pain*
I can tolerate my pain without medication*
I can still accomplish most of my life goals, despite the pain*
I can live a normal lifestyle despite the pain*
I can gradually become more active, despite the pain*

The Patient Specific Functional Scale

Select three important activities that you are unable to do or are having difficulty with as a result of your problem
Score Activity 1*
Score Activity 2*
Score Activity 3*