Activity Limitation - II. Activity Limitation or...

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II. Activity Limitation or Interference A. How much does your pain interfere with your ability to walk 1 block ? (circle a number): 0 1 2 3 4 5 6 7 8 9 10 Does not interfere Interferes always B. How much does your pain prevent you from lifting 10 pounds (a bag of groceries)? (circle a number): 0 1 2 3 4 5 6 7 8 9 10 Does not interfere Interferes always C. How much does your pain interfere with your ability to sit for ½ hour ? (circle a number): 0 1 2 3 4 5 6 7 8 9 10 Does not interfere Interferes always D. How much does your pain interfere with your ability to stand for ½ hour? (circle a number): 0 1 2 3 4 5 6 7 8 9 10 Does not interfere Interferes always E. How much does your pain interfere with your ability to get enough sleep? (circle a number): 0 1 2 3 4 5 6 7 8 9 10 Does not interfere Interferes always F. How much does your pain interfere with your ability to participate in social activities? (circle a number): 0 1 2 3 4 5 6 7 8 9 10 Does not interfere Interferes always G. How much does your pain interfere with your ability to travel up to 1 hour by car? (circle a number):
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Activity Limitation - II. Activity Limitation or...

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