Email Address

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

#1 Poor appetite or overeating?*†

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

#2 I am content

#3 Some unimportant thoughts run through my mind and bother me*

#4 I am a hotheaded person

#5 When I get mad, I say nasty things

#6 It makes me furious when I am criticized in front of others

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

#7 I wouldn’t have this much pain if there weren’t something potentially dangerous going on in my body*†

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

#8 I can’t seem to keep it out of my mind*†

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

#9 Physical activity might harm my painful body region

#10 I cannot do physical activities which (might) make my pain worse*†

#11 My work is too heavy for me*†

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

#12 During painful episodes it is difficult for me to think of anything besides the pain

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

#13 I can live a normal lifestyle, despite the pain.

Please rate the truth of each statement as it applies to you.

Never True Always True 0 1 2 3 4 5 6

#14 It’s OK to experience pain*

#15 I lead a full life even though I have chronic pain*

#16 Before I can make any serious plans, I have to get some control over my pain.

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

#17 My therapy no matter how I feel emotionally*†

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.