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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
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0
1
2
3
4
5
6
7
8
9
10
How satisfied are you with the level of care and service provided?
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Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Please rate your progress with functional activities from start of therapy to the point in time.
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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. PAIN INTENSITY
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0 - I can tolerate the pain I have without having to use pain medication
1 - The pain is bad, but I can manage without having to take pain medication
2 - Pain medication provides me with complete relief from pain
3 - Pain medication provides me with moderate relief from pain
4 - Pain medication provides me with little relief from pain
5 - Pain medication has no effect on my pain
PERSONAL CARE (washing, dressing, etc)
*
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 (eg. 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
WALKING
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0 - Pain does not prevent me from walking any distance
1 - Pain prevents me from walking more than 1 mile
2 - Pain prevents me from walking more than 1/2 mile
3 - Pain prevents me from walking more than 1/4 mile
4 - I can only walk with crutches or a cane
5 - I am in bed most of the time and have to crawl to the toilet
SITTING
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0 - I can sit in any chair as long as I like
1 - I can only sit in my favorite chair as long as I like
2 - Pain prevents me from sitting more than 1 hour
3 - Pain prevents me from sitting more than 1/2 hour
4 - Pain prevents me from sitting more than 10 minutes
5 - Pain prevents me from sitting at all
STANDING
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0 - I can stand as long as I want without increased pain
1 - I can stand as long as I want but it increases my pain
2 - Pain prevents me from standing more than 1 hour
3 - Pain prevents me from standing more than 1/2 hour
4 - Pain prevents me from standing more than 10 minutes
5 - Pain prevents me from standing at all
SLEEPING
*
0 - Pain does not prevent me from sleeping gwell
1 - I can sleep well only by using pain medication
2 - Even when I take pain medication, I sleep less than 6 hours
3 - Even when I take pain medication, I sleep less than 4 hours
4 - Even when I take pain medication, I sleep less than 2 hours
5 - Pain prevents me from sleeping at all
SOCIAL LIFE
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0 - My social life is normal and does not increase my pain
1 - My social life is normal, but it increases my level of pain
2 - Pain prevents me from participating in more energetic activities (eg, sports, dancing)
3 - Pain prevents me from going out very often
4 - Pain has restricted my social life to my home
5 - I have hardly any social life because of my pain
TRAVELING
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0 - I can travel anywhere without increased pain
1 - I can travel anywhere, but it increases my pain
2 - My pain restricts my travel over 2 hours
3 - My pain restricts my travel over 1 hour
4 - My pain restricts my travel to short necessary journeys under 1/2 hour
5 - My pain prevents all travel except for visits to the physician/therapist or hospital
EMPLOYMENT/HOMEMAKING
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0 - My normal homemaking/job activities do not cause pain
1 - My normal homemaking/job activities increase pain, but I can still perform all that is required of me
2 - I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (eg, lifting, vacuuming)
3 - Pain prevents me from doing anything but light duties
4 - Pain prevents me from doing even light duties
5 - Pain prevents me from performing any job or homemaking chores
Submit
Home
Physical Therapy
INFO
>
Locations
ONTHEGO_CALENDAR
News
Blog
Staff
>
Marc Riley
Ben Schanbacher
Casey Swartz
Melissa Palmer
Intake forms
What to expect
Services