| Number | Question | Scores |
| 1 | While laying down, do you have Sensation of mesh Pain |
0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A |
| 2 | While bending over, do you have Sensation of mesh Pain Movement limitations |
0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A |
| 3 | While sitting up, do you have Sensation of mesh Pain Movement limitations |
0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A |
| 4 | While performing activities of daily living (getting out of bed, bathing, getting dressed), do you have Sensation of mesh Pain Movement limitations |
0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A |
| 5 | When coughing or deep breathing, do you have Sensation of mesh Pain Movement limitations |
0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A |
| 6 | When walking or standing, do you have Sensation of mesh Pain Movement limitations |
0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A |
| 7 | When walking up or down stairs, do you have Sensation of mesh Pain Movement limitations |
0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A |
| 8 | When exercising (other than work-related), do you have Sensation of mesh Pain Movement limitations |
0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A 0 1 2 3 4 5 N/A |