1. Give the patient the
questionnaire corresponding to the area of pain.
2. Instruct the patient to read each description in the boxes. Circle the
letter of the line which best describes their condition relative to the boxes'
areas of function.
3. Out of view of the patient, grade the questionnaire by assigning numeric
values to each letter circled. A = Zero; B = One; C = Two; D = Three; E =
Four; and F = Five. There are 10 selections, which gives a maximum value of 50
for the questionnaire. Multiply the numeric value by 2 to obtain a score out
4. After 30 days, give a blank questionnaire to the patient. Do not allow
the patient to see what was answered previously. Score the new questionnaire
as described above. Compare the results, both numerically and by individual
sections to all previous questionnaires. This will provide an indication of
the progress with care.