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Enquiries - All Locations

Phone: (02) 4923 8900

Fax: (02) 4947 8991

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Psychometric Data

Please allow 20 minutes to complete this questionnaire below in its entirety.

If you have any questions, please phone our rooms on (02) 4923 8900.

Brief Pain Inventory

Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these kinds of pain today?(Required)

Yes

No

Please describe where on your body you feel pain the most.(Required)

Please rate your pain at its WORST in the past 24 hours.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = No pain; 10 = Pain as bad as you can imagine

Please rate your pain at its LEAST in the past 24 hours.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = No pain; 10 = Pain as bad as you can imagine

Please rate your pain at its average.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = No pain; 10 = Pain as bad as you can imagine

Please rate your pain right NOW.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = No pain; 10 = Pain as bad as you can imagine

Hidden

Average

What treatments or medicines are you receiving for your pain?(Required)

In the past 24 hours, how much relief have pain treatments or medications provided?(Required)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% = No Relief; 100% = Complete Relief

In the past 24 hours, how has the pain interfered with your General Activity.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = Does Not Interfere; 10 = Completely Interferes

In the past 24 hours, how has the pain interfered with your Mood.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = Does Not Interfere; 10 = Completely Interferes

In the past 24 hours, how has the pain interfered with your Walking Ability.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = Does Not Interfere; 10 = Completely Interferes

In the past 24 hours, how has the pain interfered with your Normal Work (includes both work outside the home and housework).(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = Does Not Interfere; 10 = Completely Interferes

In the past 24 hours, how has the pain interfered with your relation with other people.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = Does Not Interfere; 10 = Completely Interferes

In the past 24 hours, how has the pain interfered with your sleep.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = Does Not Interfere; 10 = Completely Interferes

In the past 24 hours, how has the pain interfered with your enjoyment of life.(Required)

0

1

2

3

4

5

6

7

8

9

10

0 = Does Not Interfere; 10 = Completely Interferes

Pain Catastrophizing Scale

Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Everyone experiences painful situations at some point in their lives. Such experiences include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery.

Instructions

We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the following scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.

When I'm in pain...

Rating	0	1	2	3	4
Meaning	Not at all	To a slight degree	To a moderate degree	To a great degree	All the time

I worry all the time about whether the pain will end.(Required)

0

1

2

3

4

I feel I can't go on.(Required)

0

1

2

3

4

It's terrible and I think it's never going to get any better.(Required)

0

1

2

3

4

It's awful and I feel that it overwhelms me.(Required)

0

1

2

3

4

I feel I can't stand it anymore.(Required)

0

1

2

3

4

I become afraid that the pain will get worse.(Required)

0

1

2

3

4

I keep thinking of other painful events.(Required)

0

1

2

3

4

I anxiously want the pain to go away.(Required)

0

1

2

3

4

I can't seem to keep it out of my mind.(Required)

0

1

2

3

4

I keep thinking about how much it hurts.(Required)

0

1

2

3

4

I keep thinking about how badly I want the pain to stop.(Required)

0

1

2

3

4

There's nothing I can do to reduce the intensity of the pain.(Required)

0

1

2

3

4

I wonder whether something serious may happen.(Required)

0

1

2

3

4

Hidden

Total

Tampa Scale for Kinesiophobia

Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Rating	1	2	3	4
Meaning	Strongly Disagree	Disagree	Agree	Strongly agree

1. I'm afraid that I might injury myself if I exercise(Required)

1

2

3

4

2. If I were to try to overcome it, my pain would increase(Required)

1

2

3

4

3. My body is telling me I have something dangerously wrong(Required)

1

2

3

4

4. My pain would probably be relieved if I were to exercise(Required)

1

2

3

4

5. People aren't taking my medical condition seriously enough(Required)

1

2

3

4

6. My accident has put my body at risk for the rest of my life(Required)

1

2

3

4

7. Pain always means I have injured my body(Required)

1

2

3

4

8. Just because something aggravates my pain does not mean it is dangerous(Required)

1

2

3

4

9. I'm afraid I might injure myself accidentally(Required)

1

2

3

4

10. Simply being careful that I do not make any unnecessary movements is the safest thing I can do to prevent my pain from worsening(Required)

1

2

3

4

11. I wouldn't have this much pain if there weren't something potentially dangerous going on in my body(Required)

1

2

3

4

12. Although my condition is painful, I would be better off if I were physically active(Required)

1

2

3

4

13. Pain lets me know when to stop exercising so that I don't injure myself(Required)

1

2

3

4

14. It's really not safe for a person with a condition like mine to be physically active(Required)

1

2

3

4

15. I can't do all the things normal people do because it's too easy for me to get injured(Required)

1

2

3

4

16. Even though something is causing me a lot of pain, I don't think it's actually dangerous(Required)

1

2

3

4

17. No one should have to exercise when he/ she is in pain(Required)

1

2

3

4

Hidden

Total

DASS21

Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Please read each statement and select a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

Rating	0	1	2	3
Meaning	Did not apply to me at all	Applied to me to some degree, or some of the time	Applied to me to a considerable degree, or a good part of time	Applied to me very much, or most of the time

I found it hard to wind down(Required)

0

1

2

3

I was aware of dryness of my mouth(Required)

0

1

2

3

I couldn't seem to experience any positive feeling at all(Required)

0

1

2

3

I experienced breathing difficulty (eg. excessively rapid breathing, breathlessness in the absence of physical exertion)(Required)

0

1

2

3

I found it difficult to work up the initiative to do things(Required)

0

1

2

3

I tended to over-react to situations(Required)

0

1

2

3

I experienced trembling (eg. in the hands)(Required)

0

1

2

3

I felt that I was using a lot of nervous energy(Required)

0

1

2

3

I was worried about situations in which I might panic and make a fool of myself(Required)

0

1

2

3

I felt that I had nothing to look forward to(Required)

0

1

2

3

I found myself getting agitated(Required)

0

1

2

3

I found it difficult to relax(Required)

0

1

2

3

I felt down-hearted and blue(Required)

0

1

2

3

I was intolerant of anything that kept me from getting on with what I was doing(Required)

0

1

2

3

I felt I was close to panic(Required)

0

1

2

3

I was unable to become enthusiastic about anything(Required)

0

1

2

3

I felt I wasn’t worth much as a person(Required)

0

1

2

3

I felt that I was rather touchy(Required)

0

1

2

3

I was aware of the action of my heart in the absence of physical exertion (eg. sense of heart rate increase, heart missing a beat)(Required)

0

1

2

3

I felt scared without any good reason(Required)

0

1

2

3

I felt that life was meaningless(Required)

0

1

2

3

Hidden

S

Hidden

D

Hidden

A

Pain Self Efficacy Questionnaire

Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Please rate how confident you are that you can do the following things at present, despite the pain.

To indicate your answer choose one of the numbers on the scale under each item, where 0 = not at all confident and 6 = completely confident.

I can enjoy things, despite the pain(Required)

0

1

2

3

4

5

6

I can do most of the household chores (eg. tidying-up, washing dishes etc), despite the pain(Required)

0

1

2

3

4

5

6

I can socialise with my friends or family members as often as I used to do, despite the pain(Required)

0

1

2

3

4

5

6

I can cope with my pain in most situations(Required)

0

1

2

3

4

5

6

I can do some form of work, despite the pain. ("work" includes housework, paid and unpaid work)(Required)

0

1

2

3

4

5

6

I can still do many of the things I enjoy doing, such as hobbies or leisure activity, despite pain.(Required)

0

1

2

3

4

5

6

I can cope with my pain without medication(Required)

0

1

2

3

4

5

6

I can still accomplish most of my goals in life, despite the pain(Required)

0

1

2

3

4

5

6

I can live normal lifestyle, despite the pain(Required)

0

1

2

3

4

5

6

I can gradually become more active, despite the pain(Required)

0

1

2

3

4

5

6

Hidden

Total

Enquiries
All Locations

Phone: (02) 4923 8900

Fax: (02) 4947 8991

Email: Click Here

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