Date of Completion

PROBLEMS WITH YOUR ELBOW
Patient's name (or ref)
Clinician's name (or ref)
Patient's d.o.b
INSTRUCTIONS Tick ( ) one box for every question.

1. During the past 4 weeks...

Have you had difficulty lifting things in your home, such as putting out the rubbish, because of your elbow problem?
No difficulty
A little bit of difficulty
Moderate difficulty
Extreme difficulty
Impossible to do

2. During the past 4 weeks...

Have you had difficulty carrying bags of shopping, because of your elbow problem?
No difficulty
A little bit of trouble
Moderate difficulty
Extreme difficulty
Impossible to do

3. During the past 4 weeks...

Have you had any difficulty washing yourself all over, because of your elbow problem?
No difficulty
A little bit of trouble
Moderate difficulty
Extreme difficulty
Impossible to do

4. During the past 4 weeks...

Have you had any difficulty dressing yourself, because of your elbow problem?
No difficulty
A little bit of trouble
Moderate difficulty
Extreme difficulty
Impossible to do

5. During the past 4 weeks...

Have you felt that your elbow problem is “controlling your life”?
No, not at all
Occasionally
Some days
Most days
Every days

6. During the past 4 weeks...

How much has your elbow problem been “on your mind”?
Not at all
A little of the time
Some of the time
Most of the time
All of the time

7. During the past 4 weeks...

Have you been troubled by pain from your elbow in bed at night?
Not at all
1 or 2 nights
Some nights
Most nights
Every nights

8. During the past 4 weeks...

How often has your elbow pain interfered with your sleeping?
Not at all
Occasionally
Some of the time
Most of the time
All of the time

9. During the past 4 weeks...

How much has your elbow problem interfered with your usual work or everyday activities?
Not at all
A little bit
Moderatety
Greatly
Totally

10. During the past 4 weeks...

Has your elbow problem limited your ability to take part in leisure activities that you enjoy doing?
No, not at all
Occasionally
Some of the time
Most of the time
All of the time

11. During the past 4 weeks...

How would you describe the worst pain you have from your elbow?
No pain
Mid pain
Moderate pain
Severe pain
Unbearable

12. During the past 4 weeks...

How would you describe the pain you usually have from your elbow?
No pain
Mid pain
Moderate pain
Severe pain
Unbearable

Finally, please check back that you have answered each question. Thank you very much.

PROBLEMS WITH YOUR ELBOW Score %

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Reference: Waddell C, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993; 52:157-168.

Fritz JM, George S. Identifying Psychosocial Variables in Patients With Acute Work-Related Low Back Pain: The Importance of Fear-Avoidance Beliefs. Phys Ther. 2002; 82(10): 973-983.

Lethem J, Slade PD, Troup JDG, Bendey G. Outline of a fear avoidance model of exaggerated pain perceptions, Behav Res Ther. 1983;21:401-408.

Williamson E. Fear Avoidance Behavior Questionnaire. Austrailian Journal of Physiotherapy. 2006; 52: 149.

Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eck H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62: 36, 272.