* 1. Which type of assessment will this be?

* 2. Please answer indicating how your pain intensity is affecting your everyday life.

* 3. Please answer indicating how your pain is affecting your everyday life in regards to personal care.

* 4. Please answer indicating how your pain is affecting your everyday life in regards to lifting.

* 5. Please answer indicating how your pain is affecting your everyday life in regards to reading.

* 6. Please answer indicating how your pain is affecting your everyday life in regards to headaches.

* 7. Please answer indicating how your pain is affecting your everyday life in regards to your concentration.

* 8. Please answer indicating how your pain is affecting your everyday life in regards to your work.

* 9. Please answer indicating how your pain is affecting your everyday life in regards to driving.

* 10. Please answer indicating how your pain is affecting your everyday life in regards to sleeping.

* 11. Please answer indicating how your pain is affecting your everyday life in regards to your recreational activities.

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