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* 1. Your name

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* 2. Your claim number

Here are some of the things which other patients have told us about their pain. For each statement please select any number from 0 to 6 to say how much physical activities such as bending, lifting, walking or driving affect or would affect your back pain.

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* 3. My pain was caused by physical activity

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* 4. Physical activity makes my pain worse

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* 5. Physical activity might harm my back

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* 6. I should not do physical activities which (might) make my pain worse

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* 7. I cannot do physical activities which (might) make my pain worse

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The following statements are about how your normal work affects or would affect your back pain

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* 8. My pain was caused by my work or by an accident at work

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* 9. My work aggravated my pain

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* 10. I have a claim for compensation for my pain

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* 11. My work is too heavy for me

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* 12.  My work makes or would make my pain worse

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* 13. My work might harm my back

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* 14. I should not do my normal work with my present pain

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* 15. I cannot do my normal work with my present pain

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* 16. I cannot do my normal work till my pain is treated

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* 17.  I do not think that I will be back to my normal work within 3 months

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* 18. I do not think that I will ever be able to go back to that work

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