Thank you for completing the following questionnaires. Your responses will assist your rehabilitation consultant to provide you with tailored services. It is recommended that you complete the following in a quiet environment without distractions or any assistance from others.

If you have any questions at any time please contact your consultant directly.

    Please enter your client ID number here

    K10

    The K10 is a short test about how you have been feeling over the past 4 weeks.

    1. During the last 30 days, about how often did you feel tired out for no good reason?

    None of the timeA little of the timeSome of the timeMost of the timeAll of the time

    2. During the last 30 days, about how often did you feel nervous?

    None of the timeA little of the timeSome of the timeMost of the timeAll of the time

    3. During the last 30 days, about how often did you feel so nervous that nothing could calm you down?

    None of the timeA little of the timeSome of the timeMost of the timeAll of the time

    4. During the last 30 days, about how often did you feel hopeless?

    None of the timeA little of the timeSome of the timeMost of the timeAll of the time

    5. During the last 30 days, about how often did you feel restless or fidgety?

    None of the timeA little of the timeSome of the timeMost of the timeAll of the time

    6. During the last 30 days, about how often did you feel so restless that you could not sit still?

    None of the timeA little of the timeSome of the timeMost of the timeAll of the time

    7. During the last 30 days, about how often did you feel depressed?

    None of the timeA little of the timeSome of the timeMost of the timeAll of the time

    8. During the last 30 days, about how often did you feel that everything was an effort?

    None of the timeA little of the timeSome of the timeMost of the timeAll of the time

    9. During the last 30 days, about how often did you feel so sad that nothing could cheer you up?

    None of the timeA little of the timeSome of the timeMost of the timeAll of the time

    10. During the last 30 days, about how often did you feel worthless?

    None of the timeA little of the timeSome of the timeMost of the timeAll of the time

    OREBRO12

    The Orebro is a questionnaire regarding pain, perception of daily living activities and work, and behaviour that occurs in response to pain, beliefs and attitudes.

    1. How long have you had your current pain problem> (Choose One)

    0 - 1 weeks1 - 2 weeks3 - 4 weeks4 - 5 weeks6 - 8 weeks9 - 11 weeks3 - 6 months6 - 9 months9 - 12 monthsOver 1 year

    2. Rate how much of a burden it is to perform all the things you need to do in a normal day. (Choose One)

    Not at all

    12345678910

    Extremely

    3. For the last 2-3 days, rate on average how bothersome your pain or problem is. (Choose One)

    Not at all

    12345678910

    Extremely

    4. For the last 2-3 days, what percentage of the day do you notice your pain or problem? (Choose One)

    Low

    12345678910

    High

    5. During the past 2-3 days, rate how tense or anxious you have felt. (Choose One)

    Not at all

    12345678910

    Extremely

    6. During the past 2-3 days, rate how ‘depressed’ or ‘down’ you have felt. (Choose One)

    Not at all

    12345678910

    Extremely

    7. What do you think is the risk that your current pain or problem will not improve?

    Not at all

    12345678910

    Extremely

    8. Think of your life; rate how satisfied you are with your current situation. (Choose One)

    Not at all

    12345678910

    Extremely

    How true are the next statements to you?

    9. Physical activity makes my pain or problem worse. (Choose One)

    Not at all

    12345678910

    Extremely

    10. I should not do my normal daily routine or work with my present pain or problem. (Choose One)

    Not at all

    12345678910

    Extremely

    Help us to better understand your physical capabilities.

    11. I can walk for an hour or participate in my normal light recreational or sporting activities. (Choose One)

    Not at all

    12345678910

    Extremely

    12. I manage my daily routine and social activities (e.g., shopping or transport or see friends). (Choose One)

    Not at all

    12345678910

    Extremely

    PWI

    The following questions ask how satisfied you feel, on a scale from zero to 10. Zero means you feel no satisfaction at all and 10 means you feel completely satisfied.

    Part 1. (Optional Item)

    1. Thinking about your own life and personal circumstances, how satisfied are you with your life as a whole?

    No satisfaction at all

    12345678910

    Completely satisfied

    Part 2.

    1. How satisfied are you with your standard of living?

    No satisfaction at all

    12345678910

    Completely satisfied

    2. How satisfied are you with your health?

    No satisfaction at all

    12345678910

    Completely satisfied

    3. How satisfied are you with what you are achieving in life?

    No satisfaction at all

    12345678910

    Completely satisfied

    4. How satisfied are you with your personal relationships?

    No satisfaction at all

    12345678910

    Completely satisfied

    5. How satisfied are you with how safe you feel?

    No satisfaction at all

    12345678910

    Completely satisfied

    6. How satisfied are you with feeling part of your community?

    No satisfaction at all

    12345678910

    Completely satisfied

    7. How satisfied are you with your future security?

    No satisfaction at all

    12345678910

    Completely satisfied

    8. (Optional Item) How satisfied are you with your spirituality or religion?

    No satisfaction at all

    12345678910

    Completely satisfied