Home
Physical Therapy
INFO
>
Locations
ONTHEGO_CALENDAR
News
Blog
Staff
>
Marc Riley
Ben Schanbacher
Casey Swartz
Melissa Palmer
Intake forms
What to expect
Services
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. PAIN INTENSITY
*
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)
*
0 - I can look after myself normally without extra pain
1 - I can look after myself normally, but it causes extra 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 self care
5 - I cannot get dressed, wash with difficulty, and stay in bed
LIFTING
*
0 - I can lift heavy weights without extra pain
1 - I can lift heavy weights, but it gives me extra pain
2 - Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are on a table
3 - Pain prevents me from lifting heavy weights, but I can manage if they are conveniently placed
4 - I can lift only very light weights
5 - I cannot lift or carry anything at all
HEADACHE
*
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
*
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 usual 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
*
0 - I can read as much as I want with no pain in my neck
1 - I can read as much 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
*
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
*
0 - Pain does not prevent me from sleeping well
1 - My sleep is slightly disturbed (< 1 hr sleep loss)
2 - My sleep is mildly disturbed (1-2 hr sleep loss)
3 - My sleep is moderately disturbed (2-3 hr sleep loss)
4 - My sleep is greatly disturbed (3-4 hr sleep loss)
5 - My sleep is completely disturbed (5-7 hr sleep loss)
CONCENTRATION
*
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 great difficulty concentrating when I want
5 - I cannot concentrate at all
DRIVING
*
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 pain
5 - I can't drive my car at all
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