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First Name
Last Name
Please rate your level of pain with activity
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0 - No pain
1
3
4
5
6
7
8
9
10 - Very extreme pain
How satisfied are you with the level of care and service provided?
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Please rate your progress with functional activities from start of therapy to present:
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At this point in your treatment, have your therapy goals been met?
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Pain intensity
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0 I have no pain at the moment
1 The pain is very mild at the moment
2 The pain is moderate at the moment
3 The pain is fairly severe at the moment
4 The pain is very severe at the moment
5 The pain is the worse imaginable at the moment
Personal care (washing, dressing, etc.)
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0 I can take care of myself normally without causing increased pain
1 I can take care of myself normally, but it increases my pain
2 It is painful to take care of myself, and I am slow and careful
3 I need help, but I am able to manage most of my personal care
4 I need help every day in most aspects of my care
5 I do not get dressed, wash with difficulty, and stay in bed
Lifting
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0 I can lift heavy weights without increased pain
1 I can lift heavy weights, but it causes increased pain
2 Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (e.g. on a table)
3 Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned
4 I can lift only very light weights
5 I cannot lift or carry anything at all
Headaches
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0 I have no headaches at all
1 I have slight headaches which come infrequently
2 I have moderate headaches which come infrequently
3 I have moderate headaches which come frequently
4 I have severe headaches which come infrequently
5 I have headaches almost all the time
Recreation
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0 I am able to engage in all my recreational activities without pain
1 I am able to engage in my recreational activities with some pain
2 I am able to engage in most, but not all, of my recreational activities because of my neck pain
3 I am able to engage in a few of my usual recreational activities with some neck pain
4 I can hardly do any recreational activities because of neck pain
5 I can't do any recreational activities at all
Reading
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0 I can read as much as I want with no pain in my neck
1 I can stand as long as I want with slight neck pain
2 I can read as much as I want with moderate neck pain
3 I can't read as much as I want because of moderate neck pain
4 I can hardly read at all because of severe neck pain
5 I cannot read at all because of neck pain
Work
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0 I can do as much as I want to
1 I can only do my usual work, but no more
2 I can do most of my usual work, but no more
3 I cannot do my usual work
4 I can hardly do any usual work at all
5 I can't do any work at all
Sleeping
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0 Pain does not prevent me from sleeping well
1 My sleep is slightly disturbed (<1 hour of sleep loss)
2 My sleep is mildly disturbed (1-2 hours of sleep loss)
3 My sleep is moderately disturbed (2-3 hours of sleep loss)
4 My sleep is greatly disturbed (3-4 hours of sleep loss)
5 My sleep is completely disturbed (5-7 hours of sleep loss)
Concentration
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0 I can concentrate fully when I want with no difficulty
1 I can concentrate fully when I want with slight difficulty
2 I have a fair degree of difficulty concentrating when I want
3 I have a lot of difficulty concentrating when I want
4 I have a great deal of difficulty concentrating when I want
5 I cannot concentrate at all
Driving
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0 I can drive my car without neck pain
1 I can drive my car as long as I want with slight neck pain
2 I can drive my car as long as I want with moderate neck pain
3 I can't drive my car as long as I want because of moderate pain
4 I can hardly drive my car at all because of severe neck pain
5 I can't drive my car at all
