Category 1 – Severity of the pain (during the last month) in relation to:

Walking: ( ) none ( ) mild ( ) moderate ( ) severe

Going up stairs: ( ) none ( ) mild ( ) moderate ( ) severe

Pain at night: ( ) none ( ) mild ( ) moderate ( ) severe

Pain when resting ( ) none ( ) mild ( ) moderate ( ) severe

When carrying weights: ( ) none ( ) mild ( ) moderate ( ) severe

Morning stiffness: ( ) none ( ) mild ( ) moderate ( ) severe

Protokinetic stiffness: ( ) none ( ) mild ( ) moderate ( ) severe

Category 2 – Level of difficulty in carrying out the following functions:

Going down stairs: ( ) none ( ) mild ( ) moderate ( ) severe

Going up stairs: ( ) none ( ) mild ( ) moderate ( ) severe

Getting up from a chair: ( ) none ( ) mild ( ) moderate ( ) severe

Standing up: ( ) none ( ) mild ( ) moderate ( ) severe

Bending to the ground: ( ) none ( ) mild ( ) moderate ( ) severe

Walking on a level surface: ( ) none ( ) mild ( ) moderate ( ) severe

Getting into or out of a car: ( ) none ( ) mild ( ) moderate ( ) severe

Shopping: ( ) none ( ) mild ( ) moderate ( ) severe

Putting socks on: ( ) none ( ) mild ( ) moderate ( ) severe

Getting out of bed: ( ) none ( ) mild ( ) moderate ( ) severe

Taking socks off: ( ) none ( ) mild ( ) moderate ( ) severe

Lying down on a bed: ( ) none ( ) mild ( ) moderate ( ) severe

Getting into and out of a bath: ( ) none ( ) mild ( ) moderate ( ) severe

Sitting down: ( ) none ( ) mild ( ) moderate ( ) severe

Sitting down on and getting up from the toilet:

( ) none ( ) mild ( ) moderate ( ) severe

Carrying out light domestic tasks:

( ) none ( ) mild ( ) moderate ( ) severe

Carrying out heavy domestic tasks:

( ) none ( ) mild ( ) moderate ( ) severe

Counting the points and calculating the score:

Response “none” – 4 points; “mild” – 3; “moderate” – 2; and “severe” – 0.

Total number of points: