133 N Main St.
Horseheads, NY
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Alyssa Riley
Ross Denkenberger
Casey Swartz
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Melissa Palmer
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Please circle the answers below that BEST apply
*
Indicates required field
Patient ID#
*
Please rate your pain level with activity: (0= no pain; 10 = very severe pain
*
0
1
2
3
4
5
6
7
8
9
10
How satisfied are you with the level of care and service provided?
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Please rate your progress with functional activities from start of therapy to the point in time.
*
Excellent
Good
Fair
Poor
At this point in your treatment, have your therapy goals been met?
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Completely Met
Mostly Met
Partially Met
Not Met
1. Any of your usual work, housework or school activities
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
2. Your usual hobbies, recreational or sporting activities
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
3. Getting into or out of the bath
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
4. Walking between rooms
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate of difficulty
3 - a little bit of difficulty
4 - no difficulty
5. Putting on your shoes or socks
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
6. Squatting
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
7. Lifting an object, like a bag of groceries
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
8. Performing light activities around your home
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
9. Performing heavy activities around your home
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
10. Getting into or out of a car
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
11. Walking 2 blocks
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
12. Walking a mile
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
13. Going up or down stairs (about 1 flight of stairs)
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
14. Standing for 1 hour
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
15. Sitting for 1 hour
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
16. Running on even ground
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
17. Running on even ground
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
18. Making sharp turns while running fast
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
19. Hopping
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
20. Rolling over in bed
*
0 - extreme difficulty or unable to perform activity
1 - quite a bit of difficulty
2 - moderate difficulty
3 - a little bit of difficulty
4 - no difficulty
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