UHC Optum Paperwork
Patient Summary Form
Name
First Name
Last Name
Sex
Female
Male
DOB
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Symptoms began on:
-
Month
-
Day
Year
Date
Briefly describe your symptoms:
How did your symptoms start?
Average pain intensity in the last 24 hours on a scale 0-10
0
1
2
3
4
5
6
7
8
9
10
Average pain intensity in the past week on a scale 0-10
0
1
2
3
4
5
6
7
8
9
10
How often do you experience your symptoms?
Constantly (76%-100% of the time)
frequently (51%-75% of the time)
Occasionally (26%-50% of the time)
Intermittently (0%-25% of the time)
How much have your symptoms interfered with your usual daily activities?
Not at all
A little bit
Moderately
Quite a bit
Extremely
How is your condition changing, since care began at this facility?
N/A- This is the initial visit
Much Worse
Worse
A little worse
No change
A little better
Better
Much better
In general, would you say your overall health right now is...
Excellent
Very good
Good
Fair
Poor
Signature
Back Index
Pain Intensity
The pain comes and goes and is very mild
The pain is mild and does not vary much
The pain comes and goes and is moderate
The pain is moderate and does not vary much
The pain comes and goes and is very severe
The pain is very severe and does not vary much
Sleeping
I get no pain in bed
I get pain in bed but it does not prevent me from sleeping well
Because of pain my normal sleep is reduced by less than 25%
Because of pain my normal sleep is reduced by less than 50%
Because of pain my normal sleep is reduced by less than 75%
Pain prevents me from sleeping at all
Sitting
I can sit in any chair as long as I like
I can only sit in my favorite chair as long as I like
Pain prevents me from sitting more than 1 hour
Pain prevents me from sitting more than 1/2 hour
Pain prevents me from sitting moe than 10 minutes
I avoid sitting because it increases pain immediately
Standing
I can stand as long as I want without pain
I have some pain while standing but it does not increase with time
I cannot stand for longer than 1 hour without increasing pain
I cannot stand for longer than 1/2 hour without increasing pain
I cannot stand for longer than 10 minutes without increasing pain
I avoid standing because it increases pain immediately
Walking
I have no pain while walking
I have some pain while walking but it doesn't increase with distance
I cannot walk more than 1 mile without increasing pain
I cannot walk more than 1/2 mile without increasing pain
I cannot walk more than 1/4 mile without increasing pain
I cannot walk at all without increasing pain
Personal Care
I do not have to change my way of washing or dressing in order to avoid pain
I do not normally change my way of washing or dressing even though it causes some pain
Washing and dressing increases the pain but I manage not to change my way of doing it
Washing and dressing increases the pain and I find it necessary to chnagfe my way of doing it
Because of the pain I am unable to do some washing and dressing without help
Because of the pain I am unabe to do any washing and dressing without help
Lifting
I can lift heavy weights wihtout extra pain
I can lift heavy weights but it causes extra pain
Pain prevents me from lifting heavy weights off the floor
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are convenietly positioned (e.g., on a table)
Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned
I can only lift very light weghts
Traveling
I get no pain while traveling
I get some pain while traveling but none of my usual forms of travel make it worse
I get extra pain while traveling but it does not cause me to seek alternate forms of travel
I get extra pain while traveling which causes me to seek alternate forms of travel
Pain restricts all forms of travel except that done while lying down
Pain restricts all forms of travel
Social Life
My social life is normal and gives me no extra pain
Ny social life is normal but increases the degree of pain
Pain has no significant affect onmy social life apart from limiting my more energetic interest (e.g., dancing, ect)
Pain has restricted my social life and I do not go out very often
Pain has restricted my social life to my home
I have hardly any social life because of the pain
Changing degree of pain
My pain is rapidly getting better
My pain fluctuates but overall is definitely getting better
My pain seems to be getting better but improvement is slow
My pain is neither getting better or worse
My pain is gradually worsening
My pain is rapidly worsening
Neck Index
Pain Intensity
I have no pain at the moment
The pain is very mild at the moment
The pain comes and goes and is moderate
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
Sleeping
I have no trouble sleeping
My sleep is slightly disturbed (less than 1 hour sleepless)
My sleep is mildly disturbed (1-2 hours sleepless)
My sleep is moderately disturbed (2-3 hours sleepless)
My sleep is greatly disturbed (3-5 hours sleepless)
My sleep is completely disturbed (5-7) hours sleepless)
Reading
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 cannot read as much as I want because of moderate neck pain
I can hardly read at all because of severe neck pain
I cannot read at all because of neck pain
Concentration
I can concentrate fully when I want with no difficulty
I can concentrate fully when I want with slight difficulty
I have a fair degree of difficulty concentrating when I want
I have a lot of difficulty concentrating when I want
I have a great deal of difficulty concentrating when I want
I cannot concentrate at all
Work
I can do as much work as I want
I can only do my usual work but no more
I can only 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
Personal Care
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 am I am slow and careful
I need some help but I manage most of 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
Lifting
I can lift heavy weights without extra pain
I can lift heavy weights but it causes extra pain
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table)
Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned
I can only lift very light weights
I cannot lift or carry anything at all
Driving
I can drive my car without any neck pain
I can drive my car as long as I want wiht slight neck pain
I can drive my car as long as I want with moderate neck pain
I cannot 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 cannot drive my car at all because of neck pain
Recreation
I am able to engage in all my recreation activities without neck pain
I am able to engage in all my usual recreation activities with some neck pain
I am able to engage in most but not all my usual recreation activities because of neck pain
I am only 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 cannot do any recreation activities at all
Headaches
I have no headaches at all
I have slights headaches which cone infrequently
I have moderate headaches which come infrequently
I have moderate headaches which come frequently
I have severe headaches which come frequently
I have headaches almost all the time
The Keele Start Back Screening Tool
Thinking about the last 2 weeks pick your response to the following questions:
Has your back pain spread down your leg(s) at some time in the last 2 weeks?
No
Yes
Have you had pain in the shoulder or neck at some time in the last 2 weeks?
No
Yes
Have you only walked short distances because of your back pain?
No
Yes
In the last 2 weeks, have you dressed more slowly than usual because of your back?
No
Yes
Do you think it's not really safe for a person with a condition like yours to be physically active?
No
Yes
Have worrying thoughts been going through your mind a lot of the time?
No
Yes
Do you feel that your back pain is terrible and it's never going to get any better?
No
Yes
In general have you stopped enjoying all the things you usually enjoy?
No
Yes
Overall, how bothersome has your back pain been in the last 2 weeks?
Not at all
Slightly
Moderately
Very much
Extremely
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