NAME: __________________________________________ DATE: __________________
Please rate how confident you are that you can do the following things at present, despite the pain. To indicate your answer circle one of the numbers on the scale under each item, where 0 = not at all confident and 6 = completely confident.
For example:
0 1 2 3 4 5 6
Not at all Completely
Confident confident
Remember, this questionnaire is not asking whether of not you have been doing these things, but rather how confident you are that you can do them at present, despite the pain.
1. I can enjoy things, despite the pain.
0 1 2 3 4 5 6
Not at all Completely
Confident confident
2. I can do most of the household chores (e.g. tidying-up, washing dishes, etc.), despite the pain.
0 1 2 3 4 5 6
Not at all Completely
Confident confident
3. I can socialise with my friends or family members as often as I used to do, despite the pain.
0 1 2 3 4 5 6
Not at all Completely
Confident confident
4. I can cope with my pain in most situations.
0 1 2 3 4 5 6
Not at all Completely
Confident confident
Turn over
5. I can do some form of work, despite the pain. (“work” includes housework, paid and unpaid work).
0 1 2 3 4 5 6
Not at all Completely
Confident confident
6. I can still do many of the things I enjoy doing, such as hobbies or leisure activity, despite pain.
0 1 2 3 4 5 6
Not at all Completely
Confident confident
7. I can cope with my pain without medication.
0 1 2 3 4 5 6
Not at all Completely
Confident confident
8. I can still accomplish most of my goals in life, despite the pain.
0 1 2 3 4 5 6
Not at all Completely
Confident confident
9. I can live a normal lifestyle, despite the pain.
0 1 2 3 4 5 6
Not at all Completely
Confident confident
10. I can gradually become more active, despite the pain.
0 1 2 3 4 5 6
Not at all Completely
Confident confident
Source: Nicholas M.K. Self-efficacy and chronic pain. Paper presented at the annual conference of the British
Psychological Society. St. Andrews, 1989.
Reprinted with permission from the author