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Pain Interference - Short Form 6B
Please Respond to each item by marking one box per row.
In the Past 7 days......
*
Indicates required field
How much did pain interfere with your enjoyment of life?
*
1 NOT at all
2 A little bit
3 Somewhat
4 Quite a bit
5 Very much
How much did pain interfere with your ability to concentrate?
*
1 Not at all
2 A little bit
3 Somewhat
4 Quite a bit
5 Very Much
How much did pain interfere with your day to day activities?
*
1 Not at all
2 A little bit
3 Somewhat
4 Quite a bit
5 Very much
How much did pain interfere with you enjoyment of recreational activities?
*
1 Not at all
2 A little bit
3 Somewhat
4 Quite a it
5 Very much
How much did pain interfere with doing your tasks away from home, (e.g. getting groceries, running errands)?
*
1 Not at all
2 A little bit
3 Somewhat
4 Quite a bit
5 Very Much
In the past 7 days...
How often did pain keep you from socializing with others?
*
1 Never
2 Rarely
3 Sometimes
4 Often
5 Always
Name
*
First
Last
Date
*
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Home Page
About
Services
Chiropractic Care
>
Pricing
Movement/Exercise
Contact
New Patients
Make Referral
Veterans Forms