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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.
0 days1–2 days3–7 days8–14 days15–30 days1 month2 months3–6 months6–12 monthsOver 1 year
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:
0–1 week1–2 weeks3–4 weeks4–5 weeks6–8 weeks9–11 weeks3–6 months6–9 months9–12 monthsOver 1 year
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0 = No pain – 10 = Pain as bad as it could be
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0 = No pain – 10 = Pain as bad as it could be
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0 = Never – 10 = Always
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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
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0 = Can not do because of pain – 10 = Can do without pain causing problems
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0 = Can not do because of pain – 10 = Can do without pain causing problems
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0 = Can not do because of pain – 10 = Can do without pain causing problems
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0 = Can not do because of pain – 10 = Can do without pain causing problems
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0 = Can not do because of pain – 10 = Can do without pain causing problems

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0 = Not at all – 10 = Extremely
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0 = Absolutely calm and relaxed – 10 = As tense and anxious as I’ve ever felt
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0 = Not at all – 10 = Extremely
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0 = Not risk – 10 = Very large risk
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0 = Not chance – 10 = Very large chance
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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
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0 = Completely Disagree – 10 = Completely Agree
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0 = Completely Disagree – 10 = Completely Agree
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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.