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Home
About Us
Mission Statement
Testimonials
News
Careers
Community
Services
Total Joint Surgery
Mako SmartRobotics™
Total Hip Replacement
Total Knee Replacement
Partial Knee Replacement
Joint Replacement
ROSA Robotics
Orthopedic Surgery
Spine Surgery
Minimally Invasive Spine Surgery
Disc Replacement
Laminectomy
SI Joint Fusion
Spinal Cord Stimulator
Foot & Ankle Surgery
Knee Surgery
ACL Tear
Hand Surgery
Hip Surgery
Hip Arthroscopy
Hip Labral Tear Surgery
Hip Replacement
Partial Hip Replacement
Hip Resurfacing
Periacetabular Osteotomy (PAO)
Shoulder Surgery
Rotator Cuff Surgery
Reverse Shoulder Replacement
Pain Management
Headache & Migraine Center
Sports Medicine
Patient Resources
Patient Registration
Payment Portal
Registration & Billing
Pre-Admission Testing
Surgery Prep/Recovery
Guest Amenities
Videos
How It Works (Total Knee)
How It Works (Partial Knee)
Treating Arthritis (Partial Knee)
How It Works (Total Hip)
Treating Arthritis (Total Hip)
Mako SmartRobotics™
Contact
Price Transparency
Shoppable Services
Call Now
Patient Survey Sandbox
Patient Name
Today's Date
1. Pain Intensity
I have no pain at the moment
The pain is very mild at the moment
The pain is moderate at the moment
The pain is fairly severe at the moment
The pain is very severe at the moment
The pain is the worst imaginable at the moment
2. Personal Care (Washing, Dressing, etc.)
I can look after myself normally without causing extra pain
I can look after myself normally but it causes extra pain
It is painful to look after myself and I am slow and careful
I need some help but can manage most of my personal care
I need help every day in most aspects of self-care
I do not get dressed, I wash with difficulty and stay in bed
3. Lifting
I can lift heavy weights without extra pain
I can lift heavy weights but it gives extra pain
Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table
Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned
I can only lift very light weights
I cannot lift or carry anything at all
4. Walking
Pain does not prevent me walking any distance
Pain prevents me from walking more than 1 mile
Pain prevents me from walking more than 1/2 mile
Pain prevents me from walking more than 100 yards
I can only walk using a stick or crutches
I am in bed most of the time
5. Sitting
I can sit in any chair as long as I can
I can only sit in my favorite chair as long as I like
Pain prevents me sitting more than 1 hour
Pain prevents me from sitting more than 30 minutes
Pain prevents me from sitting more than 10 minutes
Pain prevents me from sitting at all
6. Standing
I can stand as long as I want without extra pain
I can stand as long as I want but it gives me extra pain
Pain prevents from standing for more than 1 hour
Pain prevents me from standing for more than 30 minutes
Pain prevents me from standing for more than 10 minutes
Pain prevents me from standing at all
7. Sleeping
My sleep is never disturbed by pain
My sleep is occasionally disturbed by pain
Because of pain I have less than 6 hours sleep
Because of pain I have less than 4 hours sleep
Because of pain I have less than 2 hours sleep
Pain prevents me from sleeping at all
8. Sex life (if applicable)
My sex life is normal and causes no extra pain
My sex life is normal but causes some extra pain
My sex life is nearly normal but is very painful
My sex life is severely restricted by pain
My sex life is nearly absent because of pain
Pain prevents any sex life at all
9. Social Life
My social life is normal and gives me no extra pain
My social life is normal but increases the degree of pain
Pain has no significant effect on my social life apart from limiting my more energetic interests, for example sport
Pain has restricted my social life and I do not go out as often
Pain has restricted my social life to my home
I have no social life because of pain
10. Traveling
I can travel anywhere without pain
I can travel anywhere but it gives me extra pain
Pain is bad but I manage journeys over 2 hours
Pain restricts me to journeys of less than 1 hour
Pain restricts me to short necessary journeys under 30 minutes
Pain prevents me from traveling except to receive treatment
© Dr. Jeremy Fairbank. The tools listed on this website do not substitute for the informed opinion of a licensed physician or other health care provider. All scores should be re-‐checked. Please see our full Terms of Use.
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