Name
Date
Pain disability index: The rating scales below are designed to measure the degree to which aspects of your life are disrupted by chronic pain. In other words, we would like to know how much your pain is preventing you from doing what you would normally do or from doing it as well as you normally would. Respond to each category by indicating the overall impact of pain in your life, not just when the pain is at its worst.
For each of the 7 categories of life activity listed, please circle the number on the scale that describes the level of disability you typically experience. A score of 0 means no disability at all, and a score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain.
Family/Home Responsibilities: This category refers to activities of the home or family. It includes chores or duties performed around the house (eg, yard work) and errands or favors for other family members (eg, driving the children to school).
No disability
012345678910
Worst disability
Recreation: This category includes hobbies, sports, and other similar leisure time activities.
Social Activity: This category refers to activities that involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions
Occupation: This category refers to activities that are a part of or directly related to one’s job. This includes nonpaying jobs as well, such as that of a housewife or volunteer worker
Sexual Behavior: This category refers to the frequency and quality of one’s sex life.
Self‐Care: this category includes activities that involve personal maintenance and independent daily living (eg, taking a shower, driving, getting dressed, etc.)
Life‐Support Activity: This category refers to basic life‐supporting behaviors such as eating, sleeping, and breathing.
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