|
Review of system is significant for:
|
|
|
Bladder/bowel dysfunction
|
Saddle anesthesia
|
|
Recent infection
|
Unintentional weight loss
|
|
Abdominal pain
|
Memory deficits
|
|
Visual changes
|
Speech difficulties
|
|
Difficulty walking
|
Headaches
|
|
Others
|
Other (specify)
|
|
|
|
|
Neck Pain Questionnaire
|
|
|
Section 1 – Pain Intensity
|
Section 2 – Personal Care
|
|
Section 3 – Lifting
|
Section 4 – Reading
|
|
Section 5 – Headache
|
Section 6 – Concentration
|
|
Section 7 – Work
|
Section 8 - Driving
|
|
Section 9 – Sleeping
|
Section 10 – Recreation
|
|
SCORE
|
|
|
|
|
|
Oswestry Low Back Pain Disability Questionaire
|
|
|
Section 1 – Pain intensity
|
Section 2 – Personal care (washing/dressing etc)
|
|
Section 3 – Lifting
|
Section 4 – Walking
|
|
Section 5 – Sitting
|
Section 6 – Standing
|
|
Section 7 – Sleeping
|
Section 8 – Sex life (if applicable)
|
|
Section 9 – Social life
|
Section 10 – Travelling
|
|
SCORE
|
|
|
|
|
|
Opioid Risk Tool (ORT) Assessment
|
|
|
For Female
|
For Male
|
|
1. Family History of Substance Abuse
• • •
|
1. Family History of Substance Abuse
• • •
|
|
2. Personal History of Substance Abuse
• • •
|
2. Personal History of Substance Abuse
• • •
|
|
3. 16-45 years? (Score: 1)
|
3. 16-45 years? (Score: 1)
|
|
4. History of Preadolescence Sexual Abuse (Score:3)
|
4. History of Preadolescence Sexual Abuse (Score:3)
|
|
5. Psychological Disease
• • •
|
5. Psychological Disease
• • •
|
|
SCORE
|
SCORE
|
