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Please select the reason for your visit today and answer the questions that follow.
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Neck Pain
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Arm, Shoulder or Hand Pain
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Back Pain
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Lower Extremity Pain (Hip, Knee, Ankle, Foot)
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This questionnaire will give your provider information about how your neck condition affects your everyday life.
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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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(For Therapist Use Only) Neck Index Score
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Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.
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1. Open a tight or new jar.
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2. Write.
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3. Turn a key.
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4. Prepare a meal.
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5. Push open a heavy door.
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6. Place an object on a shelf above your head.
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7. Heavy household chores (e.g. wash walls, wash floors).
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8. Garden or do yard work.
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9. Make a bed.
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10. Carry a shopping bag or briefcase.
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11. Carry a heavy object (over 10 lbs.).
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12. Change a light bulb overhead.
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13. Wash or blow dry your hair.
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14. Wash your back.
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15. Put on a pullover sweater.
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16. Use a knife to cut food.
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17. Recreational activities which require little effort (e.g. card playing, knitting, etc.).
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18. Recreational activities in which your arm, shoulder or hand takes some impact (e.g., golf, tennis).
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19. Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.).
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20. Manage transportation needs (getting from one place to another).
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21. Sexual activities.
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22. To what extent has your arm, shoulder or hand problem interfered with your normal social activities?
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23. During the past week, were you limited in your work or other regular daily activities?
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Please rate the severity of the following symptoms (listed below) in the last week.
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24. Arm, shoulder or hand pain.
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25. Arm, shoulder or hand pain when you performed any specific activity.
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26. Tingling (pins and needles) in your arm, shoulder or hand.
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27. Weakness in your arm, shoulder or hand.
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28. Stiffness in your arm, shoulder or hand.
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29. During the past week, how much difficulty have you had sleeping due to your arm, shoulder or hand?
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30. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem.
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(For Therapist Use Only) DASH SCORE
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This questionnaire will give your provider information about how your back condition affects your everyday life.
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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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(For Therapist Use Only) Back Index Score
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Due to your lower limb problem, do you or would you have any difficulty at all with:
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1. Any of your usual work, housework, or school activities.
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2. Your usual hobbies, recreational or sporting activities.
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3. Getting in or out of the bath.
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4. Walking between rooms.
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5. Putting on your socks or shoes.
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6. Squatting.
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7. Lifting an object, like a bag of groceries from the floor.
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8. Performing light activities around your home.
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9. Performing heavy activities around your home.
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10. Getting into or out of a car.
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11. Walking 2 blocks.
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12. Walking a mile.
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13. Going up or down 10 stairs (1 flight of stairs).
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14. Standing for 1 hour.
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15. Sitting for 1 hour.
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16. Running on even ground.
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17. Running on uneven ground.
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18. Making sharp turns while running fast.
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19. Hopping.
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20. Rolling over in bed.
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(For Therapist Use Only) Lower Extremity Score.
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