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Neck Pain Self-Test

Are You Tired of Neck Pain?
Are You Looking For Help?

This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage everyday life. Please answer every section and mark only ONE box that applies to you. We realize that you may consider that two of the same statements in any one section relate to you, but please just mark the box that most closely describes your problem. 

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 (Washing, Dressing, etc.)

I can look after myself normally, 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 cannot get dressed; I wash with difficulty and stay in bed.

SECTION 3 - LIFTING

I can lift heavy things normally, without extra pain.

I can lift heavy weights, but it gives extra pain.

Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned; for example on a table.

Pain prevents me from lifting weights off the floor, but I can manage light to medium weights if they are 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 slight pain in my neck.

I can read as much as I want to, with moderate pain in my neck.

I can't read as much as I want because of moderate pain in my neck.

I can hardly read at all because of severe pain in my neck.

I can't read at all.

SECTION 5 - HEADACHES

I have no headaches at all.

I have slight headaches that come infrequently.

I have moderate headaches that come infrequently.

I have moderate headaches that come frequently.

I have severe headaches that come frequently.

I have headaches almost all the time.

SECTION 6 - CONCENTRATION

I can concentrate fully when I want to, with no difficulty.

I can concentrate fully when I want to, 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 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 can't do any work at all.

SECTION 8 - DRIVING

I can drive my car without any neck pain.

I can drive my car as long as I want with slight neck pain.

I can drive my car as long as I want with moderate neck pain.

I can't drive my car as long as I want because of moderate pain in my neck.

I can hardly drive at all because of severe pain in my neck.

I can't drive my car at all.

SECTION 9 - SLEEPING

I have no trouble sleeping.

My sleep is slightly disturbed (less than 1 hr sleepless).

My sleep is mildly disturbed (1-2 hrs sleepless).

My sleep is moderately disturbed (2-3 hrs sleepless).

My sleep is greatly disturbed (3-5 hrs sleepless).

My sleep is completely disturbed (5-7 hrs sleepless).

SECTION 10 - RECREATION

I am able to engage in all my recreation activities with no neck pain at all.

I am able to engage in all my recreation activities with some neck pain.

I am able to engage in most, but not all, of my usual recreation activities because of pain in my neck.

I am able to engage in few of my recreation activities because of pain in my neck.

I can hardly do any recreation activities because of pain in my neck.

I can't do any recreation activities at all.

Rate the severity of your pain:
0 (no pain) - 10 (unbearable pain) 

Full Name:
 
Street:
 
City:
 
State:
 
Zip Code:
 
Phone Number (home):
 
Phone Number (work):
 
Best Time to Call:
 
Email Address:
 

Physician's Name (please include first initial or name):
 
Physician's Street:
 
Physician's City:
 
Physician's Phone Number:
 
Describe Your Neck Problem:
 

Your personal information will never be shared or sold.
It will only be used to contact you regarding treatment.