Pain Disability Index

    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.


    No disability
    012345678910
    Worst disability


    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


    No disability
    012345678910
    Worst disability


    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


    No disability
    012345678910
    Worst disability


    Sexual Behavior: This category refers to the frequency and quality of one’s sex life.


    No disability
    012345678910
    Worst disability


    Self‐Care: this category includes activities that involve personal maintenance and independent daily living (eg, taking
    a shower, driving, getting dressed, etc.)


    No disability
    012345678910
    Worst disability


    Life‐Support Activity: This category refers to basic life‐supporting behaviors such as eating, sleeping, and breathing.


    No disability
    012345678910
    Worst disability


    Print Now