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WCB Orebro Activity Screening

Please read and answer each of the following questions. We are concerned with how your injury may be affecting your daily activities, and hope to make your outcome a safe, and efficient one. This questionnaire will help us outline and gain perspective with each individual situation.

First Name(Required)

Last Name(Required)

How many days of work have you missed because of pain you’ve experienced during the past 18 months? Please check the most appropriate time span:

Where do you experience pain? Please check all the appropriate sites:

How long have you been experiencing this pain problem? Please check most appropriate time period

Please rate the pain that you have experienced within the last week. Choose the most appropriate number on scale:

0 = No pain – 10 = Pain as bad as it could be

On average, during the past three months, how severe was your pain?

0 = No pain – 10 = Pain as bad as it could be

On average, during the past three months, how frequent were the episodes of pain that you experienced? Please choose the most appropriate rating on scale:

0 = Never – 10 = Always

Are you able to deal or cope with your pain in any way, to decrease it? This would be based on an average day, doing average things. Please choose the number that best describes the amount you can decrease your daily pain:*

0 = Can not decrease pain at all – 10 = Can decrease pain completely

The following is a short list of activities done on a daily basis. Please choose the most appropriate number on the scale(s), according to your ability to do each task

I can do light work for an hour:*

0 = Can not do because of pain – 10 = Can do without pain causing problems

I can walk for an hour:*

0 = Can not do because of pain – 10 = Can do without pain causing problems

I can do ordinary household chores:*

0 = Can not do because of pain – 10 = Can do without pain causing problems

I can go shopping:*

0 = Can not do because of pain – 10 = Can do without pain causing problems

I can sleep at night:*

0 = Can not do because of pain – 10 = Can do without pain causing problems

Is your work monotonous (dull, boring)? Please choose the best rating on scale:

0 = Not at all – 10 = Extremely

In the past week, how tense or anxious have you been feeling? Please choose the most appropriate rating on scale:

0 = Absolutely calm and relaxed – 10 = As tense and anxious as I’ve ever felt

Have you felt depressed at all in the past week? Please choose which best describes how you have been feeling:

0 = Not at all – 10 = Extremely

In your opinion, do you feel there is a risk of your pain not going away?

0 = Not risk – 10 = Very large risk

In your opinion, do you feel there is a chance you will be working in 6 months?*

0 = Not chance – 10 = Very large chance

While taking into consideration your work routine, management, your salary, the possibility for promotion, and your co-workers, how satisfied are you with your current job situation?*

0 = Not at all satisfied – 10 = Completely satisfied

The following statements were given to us by clients of our clinics regarding the pain they experience during physical activities such as bending, lifting, walking or driving. Please choose the appropriate number on the scale to help us determine the level of pain you experience while doing such activities

Physical activity makes my pain worse

0 = Completely Disagree – 10 = Completely Agree

When I feel an increase in pain, I should stop what I am doing until the pain decreases

0 = Completely Disagree – 10 = Completely Agree

I should not do my normal work with my present pain

0 = Completely Disagree – 10 = Completely Agree

This questionnaire is with reference to Steven J. Orebro, Ph.D., And Karin Hallden, B.A.

Department of Occupational and Environmental Medicine, Orebro Medical Center, Orebro, Sweden.