Patient Specific Functional and Pain Scales (PSFS) Name: Date

1 Patient Specific Functional and pain Scales (PSFS) Name: Date: Clinician Instructions: Have Patient complete after the history and before the exam Initial Assessment: We want to know what 3 activities in your life you are unable to perform, or are having the most difficulty performing, as a result of your chief problem. Please list and score at least 3 activities that you are unable to perform, or are having the most difficulty performing, because of your chief problem Follow Up Assessment: When you were assessed on _____, you told us you had difficulty with the activities in the table below. Please score these activities that you told us previously you were unable to perform or were having difficulty performing because of your chief problem. Scoring: Please score one number for each activity and for each date in the table below: Unable to Able to Perform Activity At Same Perform Activity Level As Before Injury/Problem 0 1 2 3 4 5 6 7 8 9 10 Activity Date: Date: Date: Date: Date: 1.

2 Score (0-10) Score (0-10) Score (0-10) Score (0-10) Score (0-10) 2. Score (0-10) Score (0-10) Score (0-10) Score (0-10) Score (0-10) 3. Score (0-10) Score (0-10) Score (0-10) Score (0-10) Score (0-10) 4. Score (0-10) Score (0-10) Score (0-10) Score (0-10) Score (0-10) 5. Score (0-10) Score (0-10) Score (0-10) Score (0-10) Score (0-10) Totals: Source: Straford P, Gill C, Westaway M, Binkley J. Assessing disability and change on individual patients : A report of a Patient Specific measure. Physiother Can 1995; 47:258-263. Functional Activity Back Questionnaire (FABQ) Name: Date: FABQ-PA Physical Activity: Here are some of the things that other patients have told us about their pain . For each statement, please circle any number from 0-6 to say how much physical activities, such as bending lifting, walking, or driving affect, or would affect your back pain .

3 Completely Completely Disagree Unsure Agree 1. My pain was caused by physical activity. 0 1 2 3 4 5 6 2. Physical activity makes my pain worse. 0 1 2 3 4 5 6 3. Physical activity might harm my back 0 1 2 3 4 5 6 4. I should not do physical activities which (might) make my pain worse 0 1 2 3 4 5 6 5. I cannot do physical activities which (might) make my pain worse 0 1 2 3 4 5 6 FABQ-Work: The following statements are about how your normal work affects or would affect your back.

4 Completely Completely Disagree Unsure Agree 6. My pain was caused by my work or an accident at work. 0 1 2 3 4 5 6 7. My work aggravated my pain . 0 1 2 3 4 5 6 8. I have a claim for compensation for my pain 0 1 2 3 4 5 6 9. My work is too heavy for me. 0 1 2 3 4 5 6 10. My work makes or would make my pain worse. 0 1 2 3 4 5 6 11. My work might harm my back 0 1 2 3 4 5 6 12.

5 I should not do my regular work with my present pain . 0 1 2 3 4 5 6 13. I cannot do my normal work with my present pain . 0 1 2 3 4 5 6 14. I cannot do my normal work until my pain is treated. 0 1 2 3 4 5 6 15. I do not think I will be back to my normal work within 3 months 0 1 2 3 4 5 6 16. I do not think that I will ever be able to do my normal work. 0 1 2 3 4 5 6 SCORE: FABQ-PA _____ FABQ-Work_____ Source: Waddell G, Newton M. A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefes in chronic low back pain and disablity. pain 1993;52:157-168.

6 The Keele STarT Back Screening Tool Name: Date: Thinking about the last 2 weeks tick your response to the following questions: Disagree Agree 0 1 1 My back pain has spread down my leg(s) at some time in the last 2 weeks 2 I have had pain in the shoulder or neck at some time in the last 2 weeks 3 I have only walked short distances because of my back pain 4 In the last 2 weeks, I have dressed more slowly than usual because of back pain 5 It s not really safe for a person with a condition like mine to be physically active 6 Worrying thoughts have been going through my mind a lot of the time 7 I feel that my back pain is terrible and it s never going to get any better 8 In general I have not enjoyed all the things I used to enjoy 9. Overall, how bothersome has your back pain been in the last 2 weeks?

7 Not at all Slightly Moderately Very much Extremely 0 0 0 1 1 Total score (all 9): _____ Sub Score (Q5-9):_____ Keele University 01/08/07 Funded by Arthritis Research UK Tampa scale -11 ( TSK-11) Name: Date: This is a list of phrases which other patients have used to express how the view their condition. Please circle the number that best describes how you feel about each statement. Strongly Somewhat Somewhat Strongly Disagree Disagree Agree Agree 1. I m afraid I might injure myself if I exercise. 1 2 3 4 2.

8 If I were to try to overcome it, my pain would increase. 1 2 3 4 3. My body is telling me I have something dangerously wrong. 1 2 3 4 4. People aren t taking my medical condition serious enough. 1 2 3 4 5. My accident/problem has put my body at risk for the rest of my life . 1 2 3 4 6. pain always means I have injured my body. 1 2 3 4 7. Simply being careful that I do not make any unnecessary movements is the safest thing I can do to prevent my pain from worsening. 1 2 3 4 8.

9 I wouldn t have this much pain if there wasn t something potentially dangerous going on in my body. 1 2 3 4 9. pain lets me know when to stop exercising so that I don t injure myself. 1 2 3 4 10. I can t do all the things normal people do because it s too easy for me to get injured. 1 2 3 4 11. No one should have to exercise when he/she is in pain . 1 2 3 4 Source: Woby et al. (2005), Psychometric properties of the TSK-11: A shortened version of the Tampa scale for Kinesiophobia. pain , 117, 137-144. Yellow Flags Questionnaire (YFQ) Name: Date: Please circle the appropriate response for each of the following statements or questions: 1.

10 Please indicate your usual level of pain during the past week: No pain Worst Possible pain 0 1 2 3 4 5 6 7 8 9 10 2. Does pain , numbness, tingling or weakness extend into your leg (from the low back) &/or arm (from the neck)? None Of All Of The Time The Time 0 1 2 3 4 5 6 7 8 9 10 3. How would you rate your general health? Poor Excellent 0 1 2 3 4 5 6 7 8 9 10 4.