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.

Patients Information ( please complete all of the fields below )


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.

section 1- pain intensity

section 2- personal care ( washing, dressing etc )

section 3- lifting

section 4- reading

section 5- headaches

section 6- concentration

section 7- Work

section 8- driving

section 9- sleeping

section 10- recreation

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