Not at all	A little bit	Moderately	Quite	Extremely
Work*	1	2	3	4	5
Performing household chores	1	2	3	4	5
Yard work or shopping	1	2	3	4	5
Socializing with friends	1	2	3	4	5
Recreation and hobbies	1	2	3	4	5
Having sexual relations	1	2	3	4	5
Physical exercise	1	2	3	4	5
Sleep	1	2	3	4	5
Mental efficiency	1	2	3	4	5

^*If not working because of medical or other reasons, how much do you think pain would interfere with your usual work if you were to be working?