Name *
Name
Over the last 2 weeks, how often have you been bothered by the following problems?*†
Not at All Several Days More Than Half the Days Nearly Every Day 0 1 2 3
Read each statement and select the appropriate number of the statement to indicate how you generally feel.
Almost Never Sometimes Often Almost Always 0 1 2 3
Circle the number to each question that best corresponds to how you feel
Strongly Disagree Somewhat Disagree Somewhat Agree Strongly Agree 0 1 2 3
Using the following scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.
Not at All To a Slight Degree To a Moderate Degree To a Great Degree All the Time 0 1 2 3 4
Circle the number from 0 to 6 to indicate how much physical activities affect your current pain.
Completely Disagree Completely Agree 0 1 2 3 4 5 6
Use the rating scale below to indicate how often you engage in each of the following thoughts or activities.
Never Always 0 1 2 3 4 5 6
Please rate how confident you are that you can do the following things at present, despite the pain.
Not at All Confident Completely Confident 0 1 2 3 4 5 6
Please rate the truth of each statement as it applies to you.
Never True Always True 0 1 2 3 4 5 6
Please rate your degree of certainty in performing various tasks during rehabilitation based on the following statements.
I Cannot Do it Certain I Can Do it 0 1 2 3 4 5 6 7 8 9 10
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 30, 2018. For personal use only. No other uses without permission. Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.