7. The following questions are designed to help us better understand how your neck pain
affects your ability to manage everyday life activities. Please mark in each section, the
one box that applies to you. Although you may consider that two of the statements in
any one section relate to you, please mark the box that most closely describes your
a) Pain intensity
I have no pain at the moment.
The pain is very mild at the moment.
The pain is moderate at the moment.
The pain is fairly severe at the moment.
The pain is very severe at the moment.
The pain is the worst imaginable at the moment.
b) Personal care
I can look after myself normally without causing extra pain.
I can look after myself normally, but it causes extra pain.
It is painful to look after myself, and I am slow and careful.
I need some help, but manage most of my personal care.
I need help every day in most aspects of self-care.
I do not get dressed. I wash with difficulty and stay in bed.
I can lift heavy weights without causing extra pain.
I can lift heavy weights, but it gives me extra pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if
items are conveniently positioned, i.e. on a table.
Pain prevents me from lifting heavy weights, but I can manage light weights if
they conveniently positioned.
I can lift only very light weights.
I cannot light or carry anything.
d) Work (occupational and/or personal)
I can do as much work as I want.
I can only do my usual work, but no more.
I can do most of my usual work, but no more.
I can’t do my usual work.
I can hardly do any work at all.
I cannot do any work at all.
I can concentrate fully without difficulty.
I can concentrate fully with slight difficulty.
I have a fair degree of difficulty concentrating.
I have a lot of difficulty concentrating.
I have a great deal of difficulty concentrating.
I can’t concentrate at all.
Island Health Regional Pain Program, updated 6/2015 Page 10 of 24