Pain Impact Score

Think about the past week. This is about any pain: back, neck, joints, head or elsewhere. Private. Your employer never sees your answers. This is a self-check, not a diagnosis, and you can stop anytime.

Private: your answers stay on this device and are not saved. You can stop at any time.

1. On average this week, how strong was your pain?

   None or mildModerateStrongSevere

2. Pain stopped me from sleeping or woke me up.

   Not at allNow and thenMost weeksAlmost always

3. Pain made it hard to work, study or do chores.

   Not at allNow and thenMost weeksAlmost always

4. Pain stopped me from enjoying things I usually enjoy.

   Not at allNow and thenMost weeksAlmost always

5. Pain made it hard to walk, bend, lift or get around.

   Not at allNow and thenMost weeksAlmost always

6. Pain made me irritable, low or anxious.

   Not at allNow and thenMost weeksAlmost always

7. I avoided moving because I was afraid it would make the pain worse.

   Not at allNow and thenMost weeksAlmost always

8. I took more painkillers than the label says, or used alcohol to cope with pain.

   Not at allNow and thenMost weeksAlmost always

9. How long have you had this pain?

   Less than 6 weeks6-12 weeks3-6 monthsMore than 6 months

10. Do you have new numbness around your private parts or buttocks, new trouble passing urine or controlling your bladder or bowel, or weakness in your legs?

    NoYes

11. Did you get a sudden, severe headache (the worst ever), or a headache with a stiff neck, fever, confusion, weakness or slurred speech?

    NoYes

12. Do you have chest pain or pressure, or pain spreading to the arm, jaw or back with sweating or breathlessness?

    NoYes

13. Did the pain start after a fall, accident or blow, or does it come with fever, unexplained weight loss, or a history of cancer?

    NoYes

14. Because of the pain, do you feel hopeless, or have you had thoughts that life is not worth living?

    NoSometimesOften