Name *

First Name

Last Name

Phone *

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Section 1 – Pain Intensity *

0 I have no pain at the moment

1 The pain is very mild at the moment

2 The pain is very 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 worst imaginable at the moment

Section 2 – Personal Care (washing, dressing, etc.) *

0 I can look after myself normally without causing extra pain

1 I can look after myself normally but it causes extra pain

2 It is painful to look after myself and I am slow and careful.

3 I need some help but manage most of my personal care.

4 I need help everyday in most aspects of self care.

5 I do not get dressed, I wash with difficulty and stay in bed.

Section 3 – Lifting *

0 - I can lift heavy weights without extra pain.

1 - I can lift heavy weight but it gives extra pain.

2 - Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned, for example, 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 very light weights.

5 - I cannot lift or carry anything at all.

Section 4 – Reading *

0 - I can read as much as I want to with no pain in my neck.

1 - I can read as much I want to with slight pain in my neck.

2 - I can read as much as I want with moderate pain in my neck.

3 - I can’t read as much as I want because of moderate pain in my neck.

4 - I can hardly read at all because of sever pain in my neck.

5 - I cannot read at all.

Section 5 – Headaches *

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 sever headaches which come frequently.

5 - I have headaches almost all the time.

Section 6 – Concentration *

0 - I can concentrate fully when I want to with no difficulty.

1 - I can concentrate fully when I want to with slight difficulty.

2 - I have a fair degree of difficulty in concentrating when I want to.

3 - I have a lot of difficulty in concentrating when I want to.

4 - I have a great deal of difficulty in concentrating when I want to.

5 - I cannot concentrate at all.

Section 7 – Work *

0 - I can do as much work 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 work at all.

5 - I can’t do any work at all

Section 8 – Driving *

0 - I can drive my car without any neck pain.

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

2 - I can drive my car as long as I want with moderate pain in my

neck.

3 - I can’t drive my car as long because of moderate pain in my neck.

4 - I can hardly drive at all because of sever pain in my neck.

5 - I can’t drive my car at all.

Section 9 – Sleeping *

0 - I have no trouble sleeping

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

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

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

4 - My sleep is greatly disturbed (3-4 hrs sleepless)

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

Section 10 – Recreation *

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

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

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

3 - I am able to engage in a few of my usual recreation activities because of my neck pain.

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

5 - I can’t do any recreation activities at all.