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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?
*
Completely Met
Mostly Met
Partially Met
Not Met
1. Does looking up increase your problem?
*
1 - Yes
2 - No
3 - Sometimes
2. Because of your problem, do you feel frustrated
*
1 - Yes
2 - No
3 - Sometimes
3. Because of your problem, do you restrict your travel for business or recreation
*
1 - Yes
2 - No
3 - Sometimes
4. Does walking down the aisle of a supermarket increase your problem
*
1 - Yes
2 - No
3 - Sometimes
5. Because of your problem, do you have difficulty getting into or out of bed
*
1 - Yes
2 - No
3 - Sometimes
6. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to the movies, dancing or to the parties?
*
1 - Yes
2 - No
3 - Sometimes
7. Because of your problem, do you have difficulty reading?
*
1 - Yes
2 - No
3 - Sometimes
8. Does performing more ambitious activities like sports, dancing, household chores such as sweeping or putting away dishes increase your problem
*
1 - Yes
2 - No
3 - Sometimes
9. Because of your problem, are you afraid to leave your home without having someone accompany you?
*
1 - Yes
2 - No
3 - Sometimes
10. Because of your problem, have you been embarrassed in front of others?
*
1 - Yes
2 - No
3 - Sometimes
11. Do quick movements of your head increase your problem?
*
1 - Yes
2 - No
3 - Sometimes
12. Because of your problem, do you avoid heights
*
1 - Yes
2 - No
3 - Sometimes
13. Does turning over in bed increase your problem
*
1 - Yes
2 - No
3 - Sometimes
14. Because of your problem, is it difficulty for you to do strenuous housework or yard work?
*
1 - Yes
2 - No
3 - Sometimes
15. Because of your problem, are you afraid people might think you are intoxicated
*
1 - Yes
2 - No
3 - Sometimes
16. Because of your problem, is it difficulty for you to go for a walk by yourself
*
1 - Yes
2 - No
3 - Sometimes
17. Does walking down a sidewalk increase your problem?
*
1 - Yes
2 - No
3 - Sometimes
18. Because of your problem, is it difficulty for you to concentrate?
*
1 - Yes
2 - No
3 - Sometimes
19. Because of your problem, is it difficult for you to walk around the house in the dark
*
1 - Yes
2 - No
3 - Sometimes
20. Because of your problem, are you afraid to stay home alone
*
1 - Yes
2 - No
3 - Sometimes
21. Because of your problem, do you feel handicapped?
*
1 - Yes
2 - No
3 - Sometimes
22. Has your problem placed stress on your relationships with members of your family or friends
*
1 - Yes
2 - No
3 - Sometimes
23. Because of your problem, are you depressed?
*
1 - Yes
2 - No
3 - Sometimes
24. Does your problem interfere with your job or household responsibilities?
*
1 - Yes
2 - No
3 - Sometimes
25. Does bending over increase your problem?
*
1 - Yes
2 - No
3 - Sometimes
Check the option that best describes you:
*
Negligible symptoms
Bothersome Symptoms
Performs usual work duties but symptoms interfere with outside activities
Symptoms disrupt performance of both usual work duties and outside activities
Currently on medical leave or had to change jobs because of symptoms
Unable to work for over one year or established permanent disability with compensation payments
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Home
Physical Therapy
INFO
>
Locations
ONTHEGO_CALENDAR
News
Blog
Staff
>
Marc Riley
Ben Schanbacher
Jansen Crossley
Casey Swartz
Melissa Palmer
Intake forms
What to expect
Services
