Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. Who is your Physiotherapist?

Question Title

* 3. This is a list of phrases which other patients have used to express how the view their condition. Please select the number that best describes how you feel about each statement.

  strongly disagree 1 disagree 2 agree 3 strongly agree 4
1. I’m afraid that I might injury myself if I exercise
2. If I were to try to overcome it, my pain would increase
3. My body is telling me I have something dangerously wrong
4. My pain would probably be relieved if I were to exercise
5. People aren’t taking my medical condition seriously enough
6. My accident has put my body at risk for the rest of my life
7. Pain always means I have injured my body
8. Just because something aggravates my pain does not mean it is dangerous
9. I am afraid that I might injure myself accidentally
10. Simply being careful that I do not make any unnecessary movements is the safest thing I can do to prevent my pain from worsening
11. I wouldn’t have this much pain if there weren’t something potentially dangerous going on in my body
12. Although my condition is painful, I would be better off if I were physically active
13. Pain lets me know when to stop exercising so that I don’t injure myself
14. It’s really not safe for a person with a condition like mine to be physically active
15. I can’t do all the things normal people do because it’s too easy for me to get injured
16. Even though something is causing me a lot of pain, I don’t think it’s actually dangerous
17. No one should have to exercise when he/she is in pain

Question Title

* 4. Interpretation of scores (for office use only)

Total score: add up the total scores - after inverting the values for questions 4, 8, 12, 16 (1=4, 2=3, 3=2, 4=1) = _______

MDC - not published.  SCORE RANGE = 0 (max disability) to 68 (no disability)

This questionnaire is taken from: Pain, Fear of movement/(re) injury in chronic low back pain and its relation to behavioral performance, 62, Vlaeyen, J., Kole-Snijders A., Boeren R., van Eek H., 371, 1995