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Neck Index
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Please read and once completed, turn on the switch
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Questionnaire
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Pain Intensity
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Personal Care
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Sleeping
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Lifting
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Reading
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Driving
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Concentration
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Recreation
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Work
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Headaches
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Neck Index Score
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Back Index
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Please read and once completed, turn on the switch
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Questionnaire
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Pain Intensity
• • •
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Personal Care
• • •
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Sleeping
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Lifting
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Sitting
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Traveling
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Standing
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Social Life
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Walking
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Changing degree of pain
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Back Index Score
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The Activities-specific Balance Confidence Scale
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Please indicate your level of self-confidence:
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How confident are you that you will not lose >>>
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your balance or become unsteady when you:
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Walk around the house?
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Walk up or down stairs?
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Bend and pick up a slipper from front of closet
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Reach for a small can off a shelf at eye level?
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Stand on tiptoes and reach something above head?
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Stand on a chair and reach for something?
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Sweep the floor?
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Walk outside house to a car parked in driveway?
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Get into or out of a car?
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Walk across a parking lot to the mall?
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Walk up or down a ramp?
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Walk in a crowded mall ppl rapidly walk pass you
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Are bumped into people as walk through the mall?
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Step onto/off an escalator while you hold a rail
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Walk outside on icy sidewalks?
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Step onto/off an escalator while holding onto >>
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parcels such that you cannot hold the railing?
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