middleburysportandspine-CONDITION QUESTIONNAIRE-PROGRESS

CONDITION QUESTIONNAIRE - PROGRESS
Name

First NameLast Name
Date

MonthDayYear
Date
Region of Complaint(s)
Please describe the region (back, neck, hip, etc) of your complaint(s). Include the side if applicable*
How would you describe your symptoms? (check all that apply)*

DullSharpShootingStabbingThrobbingBurningNumbnessTinglingPins and needlesCrampingTightnessStiffnessTendernessOther
Does this radiate / travel (into arms, legs, etc)?*

YesNo
If yes, please explain:
Change (if any) in activity limitations, symptoms, emotions and overall quality of life related to your condition since beginning care at our office for the above condition*

Gotten worseNo changeAlmost the same, hardly any change at allA little better, but no noticeable changeSomewhat better, but the change has not made any real differenceModerately better, and a slight but noticeable differenceBetter, and a definite improvement that has made a real and worthwhile improvementA great deal better, and a considerable improvement
Is there anything the doctor should know, anything that you would like clarification on or that you are particularity concerned about regarding this condition?*

YesNo
If yes, please explain
0-10 Severity scale

- Mild pain / symptom range: 1-3

- Moderate pain / symptom range: 4-6

- Severe pain / symptom range: 7-10

Symptom severity are rarely at a static level. Often times they will vary based on activity, time of day, position, etc. In order to better understand your symptoms, please rate how you feel now, how you feel on average (since the condition started), how you feel at its best and how you feel at its worst.
Pain / symptom level - RIGHT NOW:*

012345678910
Pain / symptom level - TYPICAL or AVERAGE (since this problem started) not how you "typically" feel*

012345678910
Pain / symptom level - AT ITS BEST*

012345678910
Pain / symptom level - AT ITS WORST*

012345678910
In order to properly assess your condition, we must understand how much your neck and/or back problems has affected your ability to manage everyday activities. For each item, please select the number which most closely describes your condition right now
1. Pain Intensity*

0 - No pain1 - Mild pain2 - Moderate pain3 - Severe pain4 - Worst possible pain
2. Sleeping*

0 - Perfect sleep1 - Mildly disturbed sleep2 - Moderately disturbed sleep3 - Greatly disturbed sleep4 - Totally disturbed sleep
3. Personal Care (washing, dressing, etc.)*

0 - No pain; no restrictions1 - Mild pain; no restrictions2 - Moderate pain; need to go slowly3 - Moderate pain; need some assistance4 - Severe pain; need 100% assistance
4. Travel (driving, etc)*

0 - No pain on long trips1 - Mild pain on long trips2 - Moderate pain on long trips3 - Moderate pain on short trips4 - Severe pain on short trips
5. Work (includes home related "work")*

0 - Can do usual work plus unlimited extra work1 - Can do usual work; no extra work2 - Can do 50% of usual work3 - Can do 25% of usual work4 - Cannot work
6. Recreation*

0 - Can do all activities1 - Can do most activities2 - Can do some activities3 - Can do a few activities4 - Cannot do any activities
7. Frequency of Pain*

0 - No pain1 - Occasional pain; 25% of the day2 - Intermittent pain; 50% of the day3 - Frequent pain; 75% of the day4 - Constant pain; 100% of the day
8. Lifting*

0 - No pain with heavy weight1 - Increased pain with heavy weight2 - Increased pain with moderate weight3 - Increased pain with light weight4 - Increased pain with any weight
9. Walking*

0 - No pain; any distance1 - Increased pain after 1 mile2 - Increased pain after 1/2 mile3 - Increased pain after 1/4 mile4 - Increased pain with all walking
10. Standing*

0 - No pain after several hours1 - Increased pain after several hours2 - Increased pain after 1 hour3 - Increased pain after 1/2 hour4 - Increased pain with any standing
Signature

Clear
Signature - to the best of my ability, the information I have supplied is complete and truthful
Should be Empty:

CONDITION QUESTIONNAIRE - PROGRESS

Region of Complaint(s)