Patient Condition Questionnaires

Please select the area(s) where you are currently experiencing symptoms:

IF YOU ARE TAKING ANY MEDICATION FOR PAIN, ANSWER THESE QUESTIONS AS IF YOU WERE NOT TAKING MEDICINE

Neck Pain Low Back Pain Shoulder, Arm or Hand Hip, Leg or Knee

Neck Pain Disability Index

AN ANSWER FOR EACH QUESTION IS REQUIRED. Please select the ONE choice in each section that most applies to you.

Section 1: Pain Intensity

I have no pain at the moment The pain is mild at the moment The pain comes and goes and is moderate The pain is moderate and does not vary much The pain is severe but comes and goes The pain is severe and does not vary much

Section 2: Personal Care

I can look after myself without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help, but manage most of my personal care I need help every day in most aspects of self-care I do not get dressed, I wash with difficulty and stay in bed

Section 3: Lifting

I can lift heavy weights without extra pain I can lift heavy weights, but it causes extra pain Pain prevents me from lifting heavy weights off the floor but I can if they are conveniently positioned Pain prevents me from lifting heavy weights, but I can manage light weights if conveniently positioned I can lift very light weights I cannot lift or carry anything at all

Section 4: Reading

I can read as much as I want to with no pain in my neck I can read as much as I want with slight pain in my neck I can read as much as I want with moderate pain in my neck I cannot read as much as I want because of moderate pain in my neck I cannot read as much as I want because of severe pain in my neck I cannot read at all

Section 5: Headache

I have no headaches at all I have slight headaches which come infrequently I have moderate headaches which come infrequently I have moderate headaches which come frequently I have severe headaches which come frequently I have headaches almost all the time

Section 6: Concentration

I can concentrate fully when I want with no difficulty I can concentrate fully when I want with slight difficulty I have a fair degree of difficulty in concentrating when I want to I have a lot of difficulty in concentrating when I want to I have a great deal of difficulty in concentrating when I want to I cannot concentrate at all

Section 7: Work

I can do as much work as I want to I can only do my usual work, but no more I can do most of my usual work, but no more I cannot do my usual work I can hardly do any work at all I cannot do any work at all Not Applicable

Section 8: Driving

I can drive my car without neck pain I can drive my car as long as I want with slight pain in my neck I can drive my car as long as I want with moderate pain in my neck I cannot drive my car as long as I want because of moderate pain I can hardly drive my car at all because of severe pain I cannot drive my car at all Not Applicable

Section 9: Sleeping

I have no trouble sleeping My sleep is slightly disturbed (less than 1 hour sleepless) My sleep is mildly disturbed (1-2 hours sleepless) My sleep is moderately disturbed (2-3 hours sleepless) My sleep is greatly disturbed (3-5 hours sleepless) My sleep is completely disturbed (5-7 hours sleepless)

Section 10: Recreation

I am able to engage in all activities with no pain I am able to engage in all activities with some pain I am able to engage in most but not all activities I am able to engage in a few of my usual activities I can hardly do any activities at all I cannot do any recreational activities at all

Low Back Pain Disability Index

AN ANSWER FOR EACH QUESTION IS REQUIRED. Please select the ONE choice in each section that most applies to you.

Section 1: Pain Intensity

I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment

Section 2: Personal Care

I can look after myself normally without extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but manage most of my personal care I need help every day in most aspects of self-care I do not get dressed, wash with difficulty and stay in bed

Section 3: Lifting

I can lift heavy weights without extra pain I can lift heavy weights but it gives extra pain Pain prevents me from lifting heavy weights off the floor Pain prevents lifting heavy weights but I manage light weights I can lift very light weights I cannot lift or carry anything at all

Section 4: Walking

Pain does not prevent me walking any distance Pain prevents me from walking more than 1 mile Pain prevents me from walking more than 1/2 mile Pain prevents me from walking more than 100 yards I can only walk using a stick or crutches I am in bed most of the time

Section 5: Sitting

I can sit in any chair as long as I like I can only sit in my favorite chair as long as I like Pain prevents me sitting more than one hour Pain prevents me from sitting more than 30 minutes Pain prevents me from sitting more than 10 minutes Pain prevents me from sitting at all

Section 6: Standing

I can stand as long as I want without extra pain I can stand as long as I want but it gives me extra pain Pain prevents me from standing for more than 1 hour Pain prevents me from standing for more than 30 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all

Section 7: Sleeping

My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours sleep Because of pain I have less than 4 hours sleep Because of pain I have less than 2 hours sleep Pain prevents me from sleeping at all

Section 8: Sex Life

My sex life is normal and causes no extra pain My sex life is normal but causes some extra pain My sex life is nearly normal but is very painful My sex life is severely restricted by pain My sex life is nearly absent because of pain Pain prevents any sex life at all

Section 9: Social Life

My social life is normal with no extra pain My social life is normal but increases the pain Pain limits energetic interests like sports Pain has restricted my social life; I don't go out often Pain has restricted my social life to my home I have no social life because of pain

Section 10: Travelling

I can travel anywhere without pain I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys over two hours Pain restricts me to journeys of less than one hour Pain restricts me to short necessary journeys under 30 mins Pain prevents me from travelling except for treatment

Disabilities of Arm, Shoulder and Hand (DASH)

AN ANSWER FOR EACH QUESTION IS REQUIRED. Please select the ONE choice in each section that most applies to you.

22. Social interference with family/friends?

No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable