Form 1_v34
  • Today's Date (MM/DD/YYYY)*
     - -

  • 2. On a scale from 0 to 10, with 0 being none and 10 being unbearable, please mark your level of pain OR discomfort for each of these areas by placing an "X" in the box of the best answer (Mark only one box for each scale).

  • Neck Pain:*
  • Right Arm Pain:*
  • Left Arm Pain:*
  • Back Pain:*
  • Right Leg Pain:*
  • Left Leg Pain:*

  • 3. Patients who have undergone spinal surgery:

  • Patient Global Impression of Improvement (PGI-I, Vikrup et al. BMC 2012) Select the number that best describes how your symptoms are now compared to before the surgery

  • LUMBAR SPINE: LOW BACK PAIN AND/OR LEG PAIN (DISCOMFORT)

    If you have low back/leg pain(or any discomfort), please answer the following 10 questions by placing an “x” in the box of the best answer. (Mark only one box for each question):

  • 1. Pain/Discomfort Intensity*
  • 2. Personal Care (EX: Washing, dressing, etc.)*
  • 3. Lifting*
  • 4. Walking*
  • 5. Sitting*
  • 6. Standing*
  • 7. Sleeping*
  • 8. Employment/Homemaking*
  • 9. Social Life*
  • 10. Traveling*

  • CERVICAL SPINE: NECK PAIN AND/OR ARM PAIN (DISCOMFORT)

    If you have neck/arm pain(or any discomfort), please answer the following 10 questions by placing an “x” in the box of the best answer. (Mark only one box for each question):

  • 1. Pain/Discomfort Intensity*
  • 2. Personal Care (EX: Washing, dressing, etc.)*
  • 3. Lifting*
  • 4. Reading*
  • 5. Headaches*
  • 6. Concentration*
  • 7. Work*
  • 8. Driving*
  • 9. Sleeping*
  • 10. Recreation*
  •  
  • Should be Empty: