Pain Outcomes Profile

Patient's Name

Patient ID No.

Today's Date

Date of Birth

How long have you had the pain for which you are now seeking treatment

Years

Months

On a scale of 0 to 10, with 0 being no pain at all and 10 being the worst possible pain, how would you rate your pain right now? 0 (No Pain ) 10 (Worst Pain Possible)

1 2 3 4 5 6 7 8 9 10

How would you rate your pain on average during the last week? 0 (No Pain) 10 (Worst Pain Possible)

1 2 3 4 5 6 7 8 9 10

Does you pain affect your self-esteem or self-worth? 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

Does your pain interfere with your ability to walk? 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

Does your pain interfere with your ability to bathe yourself? 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

How would you rate your physical activity? 0 (Significant limitation in basic activities) 10 (Can perform vigorous activities without limitation)

1 2 3 4 5 6 7 8 9 10

How would you rate your feelings of depression TODAY? 0 (Not depressed) 10 (Extremely depressed)

1 2 3 4 5 6 7 8 9 10

Does your pain interfere with your ability to carry/handle everyday objects such as a bag of groceries or books? 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

Does you pain interfere with your ability to dress yourself? 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

How would you rate your overall energy? 0 (Totally Worn out) 10 (Most Energy Ever)

1 2 3 4 5 6 7 8 9 10

How would you rate your feelings of anxiety TODAY? 0 (Not anxious at all) 10 (Extremely Anxious)

1 2 3 4 5 6 7 8 9 10

Does your pain interfere with your ability to climb stairs? 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

Does your pain interfere with your ability to use the bathroom? 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

How would you rate your strength and endurance TODAY? 0 (Very poor strength and endurance) 10 (Very high strength and endurance)

1 2 3 4 5 6 7 8 9 10

Do you have problems concentrating on things TODAY? 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

Does your pain require you to use a cane, walker, wheelchair or other devices? 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

Does your pain interfere with your ability to manage your personal grooming? (for example: combing your hair, brushing your teeth, etc.) 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

How often do you feel tense? 0 (Not at all) 10 (All the Time)

1 2 3 4 5 6 7 8 9 10

How safe do you think it is for you to exercise? 0 (Not safe at all) 10 (Extremely Safe)

1 2 3 4 5 6 7 8 9 10

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Name / Signature

Date

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