atlaschirohc.com - Pre Auth Form

PLEASE READ: Please complete this questionnaire. It is designed to give us information as to how your BACK (OR LEG) trouble has affected your ability to manage in everyday life.

Note : Please answer every section and only select one answer in each section. Selecting more than one answer will show an error. Mark one box only in each section that most closely described you today.

I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment.

I can look after myself normally without causing extra pain. I can look after myself normally but it is very painful. It is painful to look after myself and I am slow and careful. I need some help but manage most of my personal care. I need help every day in most aspects of self-care. I do not get dressed, wash with difficulty, and stay in bed.

I can lift heavy weights without extra pain. I can lift heavy weights but it gives me extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (i.e. on a table). Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can lift only very light weights. I cannot lift or carry anything at all.

Pain does not prevent me walking any distance. Pain prevents me walking more than 1mile. Pain prevents me walking more than 1⁄4 of a mile. Pain prevents me walking more than 100 yards. I can only walk using a stick or crutches. I am in bed most of the time and have to crawl to the toilet.

I can sit in any chair as long as I like. I can sit in my favorite chair as long as I like. Pain prevents me from sitting for more than 1 hour. Pain prevents me from sitting for more than 1⁄2 hour. Pain prevents me from sitting for more than 10 minutes. Pain prevents me from sitting at all.

I can stand as long as I want without extra pain. I can stand as long as I want but it gives me extra pain. Pain prevents me from standing more than 1 hour. Pain prevents me from standing for more than 1⁄2 an hour. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing at all.

My sleep is never disturbed by pain. My sleep is occasionally disturbed by pain. Because of pain, I have less than 6 hours sleep. Because of pain, I have less than 4 hours sleep. Because of pain, I have less than 2 hours sleep. Pain prevents me from sleeping at all.

Doesn't Apply My sex life is normal and causes no extra pain. My sex life is normal but causes some extra pain. My sex life is nearly normal but is very painful. My sex life is severely restricted by pain. My sex life is nearly absent because of pain. Pain prevents any sex life at all.

My social life is normal and cause me no extra pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, i.e. sports. Pain has restricted my social life and I do not go out as often. Pain has restricted social life to my home. I have no social life because of pain.

I can travel anywhere without pain. I can travel anywhere but it gives extra pain. Pain is bad but I manage journeys of over two hours. Pain restricts me to short necessary journeys under 30 minutes. Pain prevents me from traveling except to receive treatment.

PLEASE READ: Please complete this questionnaire. It is designed to give us information as to how your NECK trouble has affected your ability to manage in everyday life.

I can read as much as I want with no neck pain. I can read as much as I want with slight neck pain. I can read as much as I want with moderate neck pain. I can’t read as much as I want because of moderate neck pain. I can hardly read at all because of severe pain in my neck. I cannot read at all

I have no headaches at all. I have slight headaches that come infrequently. I have moderate headaches that come infrequently. I have moderate headaches that come frequently. I have severe headaches that come frequently. I have headaches all the time.

I can concentrate fully when I want with no difficulty. I can concentrate fully when I want to with slight difficulty. I have a fair degree of difficulty concentrating when I want to. I have a lot of difficulty concentrating when I want to. I have a great deal of difficulty concentrating when I want to. I cannot concentrate at all.

I can do as much work as I want. I can only do my usual work, but no more. I can do most of my usual work, but no more. I cannot do my usual work. I can hardly do any work at all. I cannot do any work at all.

I can drive my car without any neck pain. I can drive my car as long as I want with slight neck pain. I can drive my car as long as I want with moderate neck pain. I can’t drive my car as long as I want because of moderate neck pain. I can hardly drive at all because of severe neck pain. I can’t drive my car at all.

I have no trouble sleeping. My sleep is slightly disturbed (less than 1 hour sleepless). My sleep is mildly disturbed (1 to 2 hours sleepless). My sleep is moderately disturbed (2 to 3 hours sleepless). My sleep is greatly disturbed (3 to 5 hours sleepless). My sleep is completely disturbed (5 to 7 hours sleepless).

I am able to engage in all of my recreation activities with no neck pain. I am able to engage in all my recreation activities with some neck pain. I am able to engage in most, but not all of my usual recreation activities because of neck pain. I am able to engage in a few of my usual recreation activities because of neck pain. I can hardly do any recreation activities because of neck pain. I can’t do any recreation activities at all because of neck pain.

LOW BACK & LEG EVALUATION

NECK PAIN EVALUATION