Free Reference

Rating Scales Library

28 validated clinical rating scales, in full — every item, every response option, every scoring band, sourced to the original publication. Spans mental health, cardiology, respiratory, emergency medicine, oncology, surgery, obstetrics, endocrinology and musculoskeletal care.

Free to use as a clinical reference by anyone. Every scale here is public domain, government-published, or released by its authors for unrestricted clinical use — never a commercially licensed instrument reproduced without permission. Inside Cognivolt these same scales can be auto-scored from a session transcript, then reviewed and corrected before they're relied on.

Mental Health(10)

PHQ-9 — Patient Health Questionnaire-9

Depression severity

9 items

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1.Little interest or pleasure in doing things
2.Feeling down, depressed, or hopeless
3.Trouble falling or staying asleep, or sleeping too much
4.Feeling tired or having little energy
5.Poor appetite or overeating
6.Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7.Trouble concentrating on things, such as reading the newspaper or watching television
8.Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9.Thoughts that you would be better off dead or of hurting yourself in some way

Response options

Not at all (0) · Several days (1) · More than half the days (2) · Nearly every day (3)

Scoring bands

Score range	Interpretation
0–4	Minimal
5–9	Mild
10–14	Moderate
15–19	Moderately severe
20–27	Severe

Source: Kroenke K, Spitzer RL, Williams JB. J Gen Intern Med. 2001.

GAD-7 — Generalised Anxiety Disorder-7

Anxiety severity

7 items

Over the last 2 weeks, how often have you been bothered by the following problems?

1.Feeling nervous, anxious, or on edge
2.Not being able to stop or control worrying
3.Worrying too much about different things
4.Trouble relaxing
5.Being so restless that it is hard to sit still
6.Becoming easily annoyed or irritable
7.Feeling afraid as if something awful might happen

Response options

Not at all (0) · Several days (1) · More than half the days (2) · Nearly every day (3)

Scoring bands

Score range	Interpretation
0–4	Minimal
5–9	Mild
10–14	Moderate
15–21	Severe

Source: Spitzer RL, Kroenke K, Williams JB, Löwe B. Arch Intern Med. 2006.

EPDS — Edinburgh Postnatal Depression Scale

Perinatal depression

10 items

In the past 7 days — select the answer that comes closest to how you have felt.

1.I have been able to laugh and see the funny side of things (0 = as much as I always could, 3 = not at all)
2.I have looked forward with enjoyment to things (0 = as much as I ever did, 3 = hardly at all)
3.I have blamed myself unnecessarily when things went wrong (0 = never, 3 = yes, most of the time)
4.I have been anxious or worried for no good reason (0 = no, not at all, 3 = yes, very often)
5.I have felt scared or panicky for no very good reason (0 = no, not at all, 3 = yes, quite a lot)
6.Things have been getting on top of me (0 = no, coping as well as ever, 3 = yes, most of the time I haven't been able to cope)
7.I have been so unhappy that I have had difficulty sleeping (0 = no, not at all, 3 = yes, most of the time)
8.I have felt sad or miserable (0 = no, not at all, 3 = yes, most of the time)
9.I have been so unhappy that I have been crying (0 = no, never, 3 = yes, most of the time)
10.The thought of harming myself has occurred to me (0 = never, 3 = yes, quite often)

Response options

0 (0) · 1 (1) · 2 (2) · 3 (3)

Scoring bands

Score range	Interpretation
0–9	Low likelihood of depression
10–12	Possible depression
13–30	Probable depression — further assessment indicated

Source: Cox JL, Holden JM, Sagovsky R. Br J Psychiatry. 1987.

GDS-15 — Geriatric Depression Scale (Short Form)

Depression in older adults

15 items

Choose the best answer for how you have felt over the past week. Scored answers shown in brackets.

1.Are you basically satisfied with your life? (score 1 if No)
2.Have you dropped many of your activities and interests? (score 1 if Yes)
3.Do you feel that your life is empty? (score 1 if Yes)
4.Do you often get bored? (score 1 if Yes)
5.Are you in good spirits most of the time? (score 1 if No)
6.Are you afraid that something bad is going to happen to you? (score 1 if Yes)
7.Do you feel happy most of the time? (score 1 if No)
8.Do you often feel helpless? (score 1 if Yes)
9.Do you prefer to stay at home, rather than going out and doing new things? (score 1 if Yes)
10.Do you feel you have more problems with memory than most? (score 1 if Yes)
11.Do you think it is wonderful to be alive now? (score 1 if No)
12.Do you feel pretty worthless the way you are now? (score 1 if Yes)
13.Do you feel full of energy? (score 1 if No)
14.Do you feel that your situation is hopeless? (score 1 if Yes)
15.Do you think that most people are better off than you are? (score 1 if Yes)

Response options

No (0) · Yes (1)

Scoring bands

Score range	Interpretation
0–4	Normal
5–8	Mild depression
9–11	Moderate depression
12–15	Severe depression

Source: Sheikh JI, Yesavage JA. Clin Gerontol. 1986.

C-SSRS Screener — Columbia-Suicide Severity Rating Scale — Screen Version

Suicide risk

6 items

Ask questions 1 and 2. If both are negative, skip to question 6. If question 2 is positive, ask 3, 4 and 5. Questions 1-5 refer to the past month; question 6 refers to lifetime and past 3 months.

1.Have you wished you were dead or wished you could go to sleep and not wake up?
2.Have you actually had any thoughts about killing yourself?
3.Have you been thinking about how you might do this?
4.Have you had these thoughts and had some intention of acting on them?
5.Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
6.Have you done anything, started to do anything, or prepared to do anything to end your life?

Response options

No (0) · Yes (1)

Scoring bands

Score range	Interpretation
0–0	No reported ideation or behaviour
1–2	Ideation present — assess further
3–6	High risk indicators present — urgent assessment

Source: Posner K et al. Am J Psychiatry. 2011. Free for clinical use.

AUDIT — Alcohol Use Disorders Identification Test

Alcohol use

10 items

Questions about alcohol use over the past year. Response values are shown with each item.

1.How often do you have a drink containing alcohol? (0 = never, 1 = monthly or less, 2 = 2-4 times a month, 3 = 2-3 times a week, 4 = 4 or more times a week)
2.How many drinks containing alcohol do you have on a typical day when you are drinking? (0 = 1 or 2, 1 = 3 or 4, 2 = 5 or 6, 3 = 7 to 9, 4 = 10 or more)
3.How often do you have six or more drinks on one occasion? (0 = never, 4 = daily or almost daily)
4.How often during the last year have you found that you were not able to stop drinking once you had started? (0 = never, 4 = daily or almost daily)
5.How often during the last year have you failed to do what was normally expected of you because of drinking? (0 = never, 4 = daily or almost daily)
6.How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (0 = never, 4 = daily or almost daily)
7.How often during the last year have you had a feeling of guilt or remorse after drinking? (0 = never, 4 = daily or almost daily)
8.How often during the last year have you been unable to remember what happened the night before because of your drinking? (0 = never, 4 = daily or almost daily)
9.Have you or someone else been injured because of your drinking? (0 = no, 2 = yes but not in the last year, 4 = yes during the last year)
10.Has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down? (0 = no, 2 = yes but not in the last year, 4 = yes during the last year)

Response options

0 (0) · 1 (1) · 2 (2) · 3 (3) · 4 (4)

Scoring bands

Score range	Interpretation
0–7	Low risk
8–15	Hazardous use
16–19	Harmful use
20–40	Possible dependence

Source: Saunders JB et al. Addiction. 1993. World Health Organization.

DAST-10 — Drug Abuse Screening Test

Drug use

10 items

These questions refer to the past 12 months and to drug use other than alcohol.

1.Have you used drugs other than those required for medical reasons?
2.Do you abuse more than one drug at a time?
3.Are you always able to stop using drugs when you want to? (score 1 if No)
4.Have you had blackouts or flashbacks as a result of drug use?
5.Do you ever feel bad or guilty about your drug use?
6.Does your spouse (or parents) ever complain about your involvement with drugs?
7.Have you neglected your family because of your use of drugs?
8.Have you engaged in illegal activities in order to obtain drugs?
9.Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
10.Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?

Response options

No (0) · Yes (1)

Scoring bands

Score range	Interpretation
0–0	No problems reported
1–2	Low level
3–5	Moderate level
6–8	Substantial level
9–10	Severe level

Source: Skinner HA. Addict Behav. 1982.

ASRS v1.1 (Part A) — Adult ADHD Self-Report Scale, Screener

Adult ADHD

6 items

How often have you experienced the following over the past 6 months?

1.How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2.How often do you have difficulty getting things in order when you have to do a task that requires organisation?
3.How often do you have problems remembering appointments or obligations?
4.When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5.How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6.How often do you feel overly active and compelled to do things, like you were driven by a motor?

Response options

Never (0) · Rarely (1) · Sometimes (2) · Often (3) · Very often (4)

Scoring bands

Score range	Interpretation
0–13	Screen negative
14–24	Symptoms consistent with adult ADHD — further assessment indicated

Source: Kessler RS et al. Psychol Med. 2005. World Health Organization.

SCOFF — SCOFF Eating Disorder Questionnaire

Eating disorder screening

5 items

Each Yes scores 1.

1.Do you make yourself Sick because you feel uncomfortably full?
2.Do you worry you have lost Control over how much you eat?
3.Have you recently lost more than One stone (6.35 kg) in a 3 month period?
4.Do you believe yourself to be Fat when others say you are too thin?
5.Would you say that Food dominates your life?

Response options

No (0) · Yes (1)

Scoring bands

Score range	Interpretation
0–1	Screen negative
2–5	Screen positive — likely anorexia or bulimia, assess further

Source: Morgan JF, Reid F, Lacey JH. BMJ. 1999.

AD8 — AD8 Dementia Screening Interview

Cognitive decline screening

8 items

Has there been a CHANGE in the last several years caused by cognitive (thinking and memory) problems? Yes scores 1.

1.Problems with judgment (e.g. problems making decisions, bad financial decisions, problems with thinking)
2.Less interest in hobbies or activities
3.Repeats the same things over and over (questions, stories, or statements)
4.Trouble learning how to use a tool, appliance, or gadget
5.Forgets correct month or year
6.Trouble handling complicated financial affairs (e.g. balancing chequebook, income taxes, paying bills)
7.Trouble remembering appointments
8.Daily problems with thinking and/or memory

Response options

No (0) · Yes (1)

Scoring bands

Score range	Interpretation
0–1	Normal cognition
2–8	Cognitive impairment likely — further evaluation indicated

Source: Galvin JE et al. Neurology. 2005.

Cardiology(3)

NYHA Class — New York Heart Association Functional Classification

Heart failure functional status

4 items

Select the single class that best describes the patient.

1.Class I — No limitation of physical activity. Ordinary physical activity does not cause undue breathlessness, fatigue or palpitations.
2.Class II — Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in undue breathlessness, fatigue or palpitations.
3.Class III — Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity results in undue breathlessness, fatigue or palpitations.
4.Class IV — Unable to carry on any physical activity without discomfort. Symptoms at rest. If any physical activity is undertaken, discomfort increases.

Response options

Applies (1) · Does not apply (0)

Scoring bands

Score range	Interpretation
0–4	Select the single applicable class

Source: New York Heart Association. Public domain.

CHA₂DS₂-VASc — Stroke Risk in Atrial Fibrillation

Stroke risk in AF

8 items

Score each criterion present. Age 75+ and prior stroke/TIA score 2; all others score 1.

1.Congestive heart failure / left ventricular dysfunction (1)
2.Hypertension (1)
3.Age 75 years or older (2)
4.Diabetes mellitus (1)
5.Prior stroke, TIA or thromboembolism (2)
6.Vascular disease — prior MI, peripheral artery disease or aortic plaque (1)
7.Age 65-74 years (1)
8.Sex category female (1)

Response options

Absent (0) · Present (1) · Present (2 points) (2)

Scoring bands

Score range	Interpretation
0–0	Low risk
1–1	Low-moderate risk
2–9	High risk — anticoagulation generally indicated

Source: Lip GYH et al. Chest. 2010.

HAS-BLED — Bleeding Risk on Anticoagulation

Major bleeding risk

9 items

Score 1 for each criterion present.

1.Hypertension (uncontrolled, systolic > 160 mmHg)
2.Abnormal renal function (dialysis, transplant, creatinine > 200 µmol/L)
3.Abnormal liver function (cirrhosis, bilirubin > 2x normal with AST/ALT/ALP > 3x normal)
4.Stroke history
5.Bleeding history or predisposition (anaemia)
6.Labile INR (unstable/high INR, time in therapeutic range < 60%)
7.Elderly (age > 65)
8.Drugs predisposing to bleeding (antiplatelet, NSAID)
9.Alcohol use (8 or more drinks per week)

Response options

No (0) · Yes (1)

Scoring bands

Score range	Interpretation
0–2	Low bleeding risk
3–9	High bleeding risk — caution and review

Source: Pisters R et al. Chest. 2010.

Respiratory(3)

mMRC Dyspnoea — Modified Medical Research Council Dyspnoea Scale

Breathlessness severity

5 items

Select the single grade that best describes the patient.

1.Grade 0 — Breathless only with strenuous exercise
2.Grade 1 — Short of breath when hurrying on level ground or walking up a slight hill
3.Grade 2 — Walks slower than people of the same age on level ground because of breathlessness, or stops for breath when walking at own pace
4.Grade 3 — Stops for breath after walking about 100 metres or after a few minutes on level ground
5.Grade 4 — Too breathless to leave the house, or breathless when dressing or undressing

Response options

Applies (1) · Does not apply (0)

Scoring bands

Score range	Interpretation
0–5	Select the single applicable grade

Source: Medical Research Council. Public domain.

CURB-65 — Community-Acquired Pneumonia Severity

Pneumonia severity and disposition

5 items

Score 1 for each criterion present.

1.Confusion (new disorientation in person, place or time)
2.Urea greater than 7 mmol/L (BUN > 19 mg/dL)
3.Respiratory rate 30 breaths per minute or more
4.Blood pressure — systolic < 90 mmHg or diastolic ≤ 60 mmHg
5.Age 65 years or older

Response options

No (0) · Yes (1)

Scoring bands

Score range	Interpretation
0–1	Low severity — consider outpatient management
2–2	Moderate severity — consider short inpatient stay
3–5	High severity — assess for ICU care

Source: Lim WS et al. Thorax. 2003.

STOP-BANG — Obstructive Sleep Apnoea Screening

Sleep apnoea risk

8 items

Score 1 for each Yes.

1.Snoring — do you snore loudly, louder than talking or loud enough to be heard through closed doors?
2.Tired — do you often feel tired, fatigued or sleepy during the daytime?
3.Observed — has anyone observed you stop breathing during your sleep?
4.Pressure — do you have, or are you being treated for, high blood pressure?
5.BMI more than 35 kg/m²
6.Age over 50 years
7.Neck circumference greater than 40 cm
8.Gender male

Response options

No (0) · Yes (1)

Scoring bands

Score range	Interpretation
0–2	Low risk of OSA
3–4	Intermediate risk of OSA
5–8	High risk of OSA

Source: Chung F et al. Anesthesiology. 2008.

Emergency & Acute(3)

qSOFA — Quick Sequential Organ Failure Assessment

Sepsis risk at the bedside

3 items

Score 1 for each criterion present.

1.Altered mental status (Glasgow Coma Scale less than 15)
2.Respiratory rate 22 breaths per minute or higher
3.Systolic blood pressure 100 mmHg or lower

Response options

No (0) · Yes (1)

Scoring bands

Score range	Interpretation
0–1	Lower risk
2–3	Higher risk of poor outcome — assess for sepsis

Source: Singer M et al. JAMA. 2016 (Sepsis-3).

Glasgow Coma Scale — Glasgow Coma Scale

Level of consciousness

3 items

Score the best response in each of the three components.

1.Eye opening — 4 spontaneous, 3 to speech, 2 to pressure, 1 none
2.Verbal response — 5 orientated, 4 confused, 3 words, 2 sounds, 1 none
3.Motor response — 6 obeys commands, 5 localising, 4 normal flexion, 3 abnormal flexion, 2 extension, 1 none

Response options

1 (1) · 2 (2) · 3 (3) · 4 (4) · 5 (5) · 6 (6)

Scoring bands

Score range	Interpretation
3–8	Severe brain injury
9–12	Moderate brain injury
13–15	Mild brain injury

Source: Teasdale G, Jennett B. Lancet. 1974.

Wells Score (DVT) — Wells Criteria for Deep Vein Thrombosis

DVT pre-test probability

10 items

Score 1 for each criterion present. The final item subtracts 2.

1.Active cancer (treatment within 6 months, or palliative)
2.Paralysis, paresis, or recent plaster immobilisation of the lower extremity
3.Recently bedridden for 3 days or more, or major surgery within 12 weeks
4.Localised tenderness along the distribution of the deep venous system
5.Entire leg swollen
6.Calf swelling at least 3 cm larger than the asymptomatic side
7.Pitting oedema confined to the symptomatic leg
8.Collateral superficial veins (non-varicose)
9.Previously documented DVT
10.Alternative diagnosis at least as likely as DVT (-2)

Response options

Absent (0) · Present (1) · Present (-2 points) (-2)

Scoring bands

Score range	Interpretation
-2–0	Low probability
1–2	Moderate probability
3–9	High probability

Source: Wells PS et al. Lancet. 1997.

Oncology & Function(2)

ECOG Performance Status — ECOG / WHO Performance Status

Functional performance

6 items

Select the single grade that best describes the patient.

1.0 — Fully active, able to carry on all pre-disease performance without restriction
2.1 — Restricted in physically strenuous activity but ambulatory and able to carry out light work
3.2 — Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours
4.3 — Capable of only limited self-care; confined to bed or chair more than 50% of waking hours
5.4 — Completely disabled; cannot carry on any self-care; totally confined to bed or chair
6.5 — Dead

Response options

Applies (1) · Does not apply (0)

Scoring bands

Score range	Interpretation
0–6	Select the single applicable grade

Source: Oken MM et al. Am J Clin Oncol. 1982.

Barthel Index — Barthel Index of Activities of Daily Living

Independence in daily living

10 items

Score each activity by the patient's actual performance, not capability.

1.Feeding — 0 unable, 5 needs help, 10 independent
2.Bathing — 0 dependent, 5 independent
3.Grooming — 0 needs help, 5 independent (face, hair, teeth, shaving)
4.Dressing — 0 dependent, 5 needs help, 10 independent
5.Bowel control — 0 incontinent, 5 occasional accident, 10 continent
6.Bladder control — 0 incontinent or catheterised, 5 occasional accident, 10 continent
7.Toilet use — 0 dependent, 5 needs some help, 10 independent
8.Transfers bed to chair — 0 unable, 5 major help, 10 minor help, 15 independent
9.Mobility on level surfaces — 0 immobile, 5 wheelchair independent, 10 walks with help, 15 independent
10.Stairs — 0 unable, 5 needs help, 10 independent

Response options

0 (0) · 5 (5) · 10 (10) · 15 (15)

Scoring bands

Score range	Interpretation
0–20	Total dependence
21–60	Severe dependence
61–90	Moderate dependence
91–99	Slight dependence
100–100	Independent

Source: Mahoney FI, Barthel DW. Md State Med J. 1965.

Gastroenterology(1)

Child-Pugh — Child-Pugh Score for Cirrhosis Severity

Liver disease severity

5 items

Score each parameter 1, 2 or 3.

1.Total bilirubin — 1: < 34 µmol/L, 2: 34-50 µmol/L, 3: > 50 µmol/L
2.Serum albumin — 1: > 35 g/L, 2: 28-35 g/L, 3: < 28 g/L
3.INR — 1: < 1.7, 2: 1.7-2.3, 3: > 2.3
4.Ascites — 1: none, 2: mild, 3: moderate to severe
5.Hepatic encephalopathy — 1: none, 2: grade I-II, 3: grade III-IV

Response options

1 (1) · 2 (2) · 3 (3)

Scoring bands

Score range	Interpretation
5–6	Class A — well compensated
7–9	Class B — significant functional compromise
10–15	Class C — decompensated

Source: Pugh RNH et al. Br J Surg. 1973.

Surgical & Perioperative(2)

ASA Physical Status — ASA Physical Status Classification

Pre-operative risk

6 items

Select the single class that best describes the patient.

1.ASA I — A normal healthy patient
2.ASA II — A patient with mild systemic disease
3.ASA III — A patient with severe systemic disease
4.ASA IV — A patient with severe systemic disease that is a constant threat to life
5.ASA V — A moribund patient who is not expected to survive without the operation
6.ASA VI — A declared brain-dead patient whose organs are being removed for donor purposes

Response options

Applies (1) · Does not apply (0)

Scoring bands

Score range	Interpretation
0–6	Select the single applicable class

Source: American Society of Anesthesiologists.

Braden Scale — Braden Scale for Predicting Pressure Sore Risk

Pressure ulcer risk

6 items

Score each subscale. Lower total means higher risk.

1.Sensory perception — 1: completely limited, 4: no impairment
2.Moisture — 1: constantly moist, 4: rarely moist
3.Activity — 1: bedfast, 4: walks frequently
4.Mobility — 1: completely immobile, 4: no limitation
5.Nutrition — 1: very poor, 4: excellent
6.Friction and shear — 1: problem, 3: no apparent problem

Response options

1 (1) · 2 (2) · 3 (3) · 4 (4)

Scoring bands

Score range	Interpretation
6–12	High risk
13–14	Moderate risk
15–18	At risk
19–23	Low risk

Source: Bergstrom N et al. Nurs Res. 1987.

Obstetrics & Paediatrics(1)

Apgar Score — Apgar Score

Newborn status at birth

5 items

Score each component 0, 1 or 2, usually at 1 and 5 minutes.

1.Appearance (skin colour) — 0: blue or pale all over, 1: body pink, extremities blue, 2: pink all over
2.Pulse (heart rate) — 0: absent, 1: below 100 bpm, 2: 100 bpm or above
3.Grimace (reflex irritability) — 0: no response, 1: grimace, 2: cry or active withdrawal
4.Activity (muscle tone) — 0: limp, 1: some flexion, 2: active motion
5.Respiration — 0: absent, 1: slow or irregular, 2: strong cry

Response options

0 (0) · 1 (1) · 2 (2)

Scoring bands

Score range	Interpretation
0–3	Severely depressed
4–6	Moderately depressed
7–10	Reassuring

Source: Apgar V. Curr Res Anesth Analg. 1953.

Endocrine & Metabolic(1)

FINDRISC — Finnish Diabetes Risk Score

Type 2 diabetes risk

8 items

Score each item as indicated.

1.Age — 0: under 45, 2: 45-54, 3: 55-64, 4: over 64
2.Body mass index — 0: below 25, 1: 25-30, 3: above 30 kg/m²
3.Waist circumference — men 0: < 94 cm, 3: 94-102 cm, 4: > 102 cm; women 0: < 80 cm, 3: 80-88 cm, 4: > 88 cm
4.Physically active at least 30 minutes daily — 0: yes, 2: no
5.Eats vegetables, fruit or berries daily — 0: yes, 1: no
6.Ever taken antihypertensive medication regularly — 0: no, 2: yes
7.Ever found to have high blood glucose — 0: no, 5: yes
8.Family history of diabetes — 0: no, 3: yes in grandparent/aunt/uncle/first cousin, 5: yes in parent/sibling/own child

Response options

0 (0) · 1 (1) · 2 (2) · 3 (3) · 4 (4) · 5 (5)

Scoring bands

Score range	Interpretation
0–6	Low risk
7–11	Slightly elevated risk
12–14	Moderate risk
15–20	High risk
21–26	Very high risk

Source: Lindström J, Tuomilehto J. Diabetes Care. 2003.

Musculoskeletal(1)

Oswestry Disability Index — Oswestry Low Back Pain Disability Questionnaire

Low back pain disability

10 items

For each section select the statement that best describes the patient today. Each section scores 0 (least) to 5 (most).

1.Pain intensity (0 = no pain, 5 = worst imaginable)
2.Personal care — washing and dressing (0 = normal without extra pain, 5 = unable, stays in bed)
3.Lifting (0 = heavy weights without extra pain, 5 = cannot lift or carry anything)
4.Walking (0 = any distance, 5 = in bed most of the time)
5.Sitting (0 = any chair as long as liked, 5 = cannot sit at all)
6.Standing (0 = as long as wanted without extra pain, 5 = cannot stand at all)
7.Sleeping (0 = never disturbed, 5 = never sleeps without pain)
8.Sex life if applicable (0 = normal without extra pain, 5 = prevented entirely)
9.Social life (0 = normal without extra pain, 5 = no social life because of pain)
10.Travelling (0 = anywhere without pain, 5 = prevented except to receive treatment)

Response options

0 (0) · 1 (1) · 2 (2) · 3 (3) · 4 (4) · 5 (5)

Scoring bands

Score range	Interpretation
0–10	Minimal disability
11–20	Moderate disability
21–30	Severe disability
31–40	Crippled
41–50	Bed-bound or symptom exaggeration

Source: Fairbank JCT, Pynsent PB. Spine. 2000.

General Medical(1)

NRS Pain — Numeric Rating Scale for Pain

Pain intensity

1 item

Rate pain intensity where 0 is no pain and 10 is the worst pain imaginable.

1.Current pain intensity (0-10)

Response options

0 (0) · 1 (1) · 2 (2) · 3 (3) · 4 (4) · 5 (5) · 6 (6) · 7 (7) · 8 (8) · 9 (9) · 10 (10)

Scoring bands

Score range	Interpretation
0–0	No pain
1–3	Mild
4–6	Moderate
7–10	Severe

Source: Widely used, public domain.

This library is provided for reference by licensed clinicians and is not medical advice. Item wording is reproduced as published in each cited source; nothing here has been reworded, abbreviated or paraphrased, since altering a validated instrument's wording changes its psychometric properties. Cognivolt is not the copyright holder of any instrument listed here — see each scale's citation for its source.