Please complete the Early Intervention Assessment below:

1. Please select which one reflects your current age.
< 18 - 26	27 - 35	36 - 44	45 - 53	54+ years

2. How many days of work have you missed because of this injury?
0	1 - 2	3 - 7	8 - 14	15+ days

3. How long have you had your current pain problem?
0 - 1 weeks	1 - 2 weeks	3 - 4 weeks	5 - 5 weeks	6 - 8 weeks
9 - 11 weeks	3 - 6 months	6 - 9 months	9 - 12 months	Over 1 year

4. Is your work heavy or monotonous? Select the best alternative.
0	1	2	3	4	5	6	7	8	9	10

Not at all

Extremely

5. How would you rate the pain you have had during the past week?
0	1	2	3	4	5	6	7	8	9	10

No pain

Pain as bad as it could be

6. How tense or anxious have you felt in the past week?
0	1	2	3	4	5	6	7	8	9	10

Absolutely calm and relaxed

As tense and anxious as I've ever felt

7. How much have you been bothered by feeling depressed in the past week?
0	1	2	3	4	5	6	7	8	9	10

Not at all

Extremely

8. In your view, how large is the risk that your current pain may become persistent?
0	1	2	3	4	5	6	7	8	9	10

No risk

Very large risk

Here are some of the things that other people have told us about their pain. For each statement please select a number from 0 - 10 to say how much physical activities, such as bending and lifting, affect your pain.

9. Physical activity makes my pain worse.
0	1	2	3	4	5	6	7	8	9	10

Completely disagree

Completely agree

10. An increase in pain is an indication that I should stop what I'm doing until the pain decreases.
0	1	2	3	4	5	6	7	8	9	10

Completely disagree

Completely agree

11. I should not do my normal work with my present pain.
0	1	2	3	4	5	6	7	8	9	10

Completely disagree

Completely agree

12. In your estimation, what are the chances you will be working your normal duties in 3 months?
0	1	2	3	4	5	6	7	8	9	10

No chance

Very large chance

Orebro Musculoskeletal Pain Screening Questionnaire (modified for early injury intervention by Pearce & McGarity, 2008)¹
1. Linton SJ, Hallden K. Can we screen for back pain? A screening questionnaire for predicting the outcome in acute
and subacute back pain. Clin J Pain 1998 Se; 14(3): 209-15.