GENERAL PAIN INDEX QUESTIONNAIRE
We would like to know how much your pain PRESENTLY prevents you from doing what you would normally do.
Regarding each category, please indicate the OVERALL impact your present pain has on your life, not just when the pain
is at its worst.
NAME:______________________________________________ DATE:_________________
Please write the number which best describes how your typical level of pain affects these six categories of activities.
0______1_______2_______3_______4_______5_______6_______7________8______9_____10_____
completely
totally unable
able to function
to function
1.Family/at-home responsibilities such as yard work, chores around the house or driving the kids to school. ________
2. Recreation including hobbies, sports, reading and other leisure activities:______________
3. Social activities including parties theater, concerts, dining out and attending other social functions with
friends:______
4. Employment including volunteer work and homemaking tasks ______
5. Self-care such as taking a shower, driving, or getting dressed:_______
6. Life support activities such as eating and sleeping:________
Score:_________________ (60)
Benchmark - 5 __________________
BACK AND NECK INDEX
This questionnaire gives information about how your back/neck condition affects your
everyday life. Please answer every section by circling the one statement that applies to you.
PAIN INTENSITY
STANDING
0 The pain comes and goes and is very mild.
0 I can stand as long as I want without pain
1 The pain is mild and does not vary much
1 I have some pain while standing but it does not increase with time
2 The pain comes and goes and is moderate
2 I cannot stand for longer than 1 hours
3 The pain is moderate and does not vary much
3 I cannot stand longer than 1/2 hour
4 The pain comes and goes and is very severe
4 I cannot stand for longer than 10 minutes
5 The pain is very severe and does not vary much. 5 I avoid standing because it increases pain
SLEEPING
WALKING
0 I get no pain in bed.
0 I have no pain while walking
1 I get pain but it doesn't prevent me from sleeping 1 I have some pain while walking
2 My normal sleep is reduced by less than 25%
2 I can't walk more than 1 mile without pain
3 My normal sleep is reduced by less than 50%
3 I can't walk more than 1/2 mile without pain
4 My normal sleep is reduced by less than 75%
4 I can't walk more than 1/4 mile without pain
5 Pain prevents me from sleeping at all
5 I can't walk at all without pain
SITTING
LIFTING
0 I can sit in any chair as long as I like.
0 I can lift heavy weights without extra pain
1 I can only sit in my favorite chair as long as I like
1 I can lift heavy weights but it causes pain
2 Pain prevents me from sitting more than 1 hour
2 Pain prevents me from lifting heavy weights off the floor
3 Pain prevents me from sitting more than 1/2 hour 3 Pain prevents me from lifting heavy weights off the floor, but I can off a table
4 Pain prevents me from sitting more than 10 minutes 4 Pain prevents me from lifting heavy weights but I can lift moderate weights
5 I avoid sitting because it increases pain immediately 5 I can only lift very light weights.
HEADACHES: 0 I have no headaches at all 1 I have slight headaches which come infrequently 2 I have moderate headaches which
come infrequently 3 I have moderate headaches which come frequently 4 I have severe headaches which come frequently 5 I have
headaches almost all the time.