Activities of Daily Living

Type your name please

How severely is your pain/tightness affecting your job performance?

If anything doesn't apply, mark no effect for this question and the following ones

How severely is your pain/tightness affecting your ability to bend over?

How severely does your pain/tightness affect your ability to care for sick family members?

How severely does your pain/tightness affect your ability to carry groceries?

How severely does your pain/tightness affect your ability to go from lying down to sitting up?

How severely does your pain/tightness affect your ability to go from sitting to standing?

How severely does your pain/tightness affect your ability to climb stairs?

How severely does your pain/tightness affect your ability to drive?

How severely does your pain/tightness affect your ability to use your computer or phone for an extended amount of time?

How severely does your pain/tightness affect your ability to eat?

How severely does your pain/tightness affect your ability to do household chores?

How severely does your pain/tightness affect your ability to kneel down?

How severely does your pain/tightness affect your ability to lift children or pets?

I can lift ______ but it causes me pain

How severely does your pain/tightness affect your ability to take care of your pet?

How severely does your pain/tightness affect your ability to read or concentrate?

Is your pain or tightness so bad that it's affecting your ability to think?

How severely does your pain/tightness affect your ability to bathe yourself?

How severely does your pain/tightness affect your ability to dress yourself?

How severely does your pain/tightness affect your ability to shave yourself or wash your hair?

How severely does your pain/tightness affect your sexual activities?

How severely does your pain/tightness affect your ability to sleep?

How severely does your pain/tightness affect your ability to sit without moving?

How severely does your pain/tightness affect your ability to stand?

How severely does your pain/tightness affect your ability to walk?

How severely does your pain/tightness affect your ability to do yard work?

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