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neck disability

Neck disability

Welcome to the healthcare management goup inc.! In order to serve ypu better, please take a moment to complete this form, if you require assistance, please call or email the office.

oswestry low back disability form

Patients Information ( please complete all of the fields below )

Instructions

This questionnaire has been designed to give us information as to how you back or leg pain is affecting your ability to manage in everyday life, please answer by clicking ONE option each section for the statement which best applies to you. We realise you can consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem.

Layout

section 1- pain intensity

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

section 2- personal care ( washing, dressing etc )

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

section 3- lifting

I can lift heavy weights without extra pain
I can lift heavy weights but it gives extra pain
Pain prevents me from lifting heavy weights off the floor, but i can manage if they are conveniently placed eg. 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 very light weights
I cannot lift or carry anything at all

section 4- reading

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

section 5- headaches

I have no headaches at all
I have slight headaches, which comes infrequently
I have moderate headaches, which comes infrequently
I have moderate headaches, which comes frequently
I have severe headaches, which comes frequently
I have headaches almost all the time

section 6- concentration

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

section 7- Work

I can do as much as i want to
I can only do mu 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 can’t do any work at all

section 8- driving

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

section 9- sleeping

I have no trouble sleeping
My sleep is slightly disturbed ( less than 1 hr sleepless )
My sleep is mildly disturbed ( 1-2 hrs sleepless )
My sleep is moderately is disturbed ( 2-3 hrs sleepless )
My sleep is greatly disturbed ( 3-5 hrs sleepless )
My sleep is completely disturbed ( 5-7 hrs sleepless )

section 10- recreation

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

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