Optum Papers

UHC Optum Paperwork
Patient Summary Form
Name

First NameLast Name
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DOB

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Date
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Symptoms began on:

MonthDayYear
Date
Briefly describe your symptoms:
How did your symptoms start?
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Constantly (76%-100% of the time)frequently (51%-75% of the time)Occasionally (26%-50% of the time)Intermittently (0%-25% of the time)
Not at allA little bitModeratelyQuite a bitExtremely
N/A- This is the initial visitMuch WorseWorseA little worseNo changeA little betterBetterMuch better
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Back Index
The pain comes and goes and is very mildThe pain is mild and does not vary muchThe pain comes and goes and is moderateThe pain is moderate and does not vary muchThe pain comes and goes and is very severeThe pain is very severe and does not vary much
I get no pain in bedI get pain in bed but it does not prevent me from sleeping wellBecause 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
I can sit in any chair as long as I likeI can only sit in my favorite chair as long as I likePain prevents me from sitting more than 1 hourPain prevents me from sitting more than 1/2 hourPain prevents me from sitting moe than 10 minutesI avoid sitting because it increases pain immediately
I can stand as long as I want without painI have some pain while standing but it does not increase with timeI cannot stand for longer than 1 hour without increasing painI cannot stand for longer than 1/2 hour without increasing painI cannot stand for longer than 10 minutes without increasing painI avoid standing because it increases pain immediately
I have no pain while walkingI have some pain while walking but it doesn't increase with distanceI cannot walk more than 1 mile without increasing painI cannot walk more than 1/2 mile without increasing painI cannot walk more than 1/4 mile without increasing painI cannot walk at all without increasing pain
I do not have to change my way of washing or dressing in order to avoid painI do not normally change my way of washing or dressing even though it causes some painWashing and dressing increases the pain but I manage not to change my way of doing itWashing and dressing increases the pain and I find it necessary to chnagfe my way of doing itBecause of the pain I am unable to do some washing and dressing without helpBecause of the pain I am unabe to do any washing and dressing without help
I can lift heavy weights wihtout extra painI can lift heavy weights but it causes extra painPain prevents me from lifting heavy weights off the floorPain 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 positionedI can only lift very light weghts
I get no pain while travelingI get some pain while traveling but none of my usual forms of travel make it worseI get extra pain while traveling but it does not cause me to seek alternate forms of travelI get extra pain while traveling which causes me to seek alternate forms of travelPain restricts all forms of travel except that done while lying downPain restricts all forms of travel
My social life is normal and gives me no extra painNy social life is normal but increases the degree of painPain 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 oftenPain has restricted my social life to my homeI have hardly any social life because of the pain
My pain is rapidly getting betterMy pain fluctuates but overall is definitely getting betterMy pain seems to be getting better but improvement is slowMy pain is neither getting better or worseMy pain is gradually worseningMy pain is rapidly worsening
Neck Index
I have no pain at the momentThe pain is very mild at the momentThe pain comes and goes and is moderateThe pain is fairly severe at the momentThe pain is very severe at the momentThe pain is the worst imaginable at the moment
I have no trouble sleepingMy 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)
I can read as much as I want with no neck painI can read as much as I want with slight neck painI can read as much as I want with moderate neck painI cannot read as much as I want because of moderate neck painI can hardly read at all because of severe neck painI cannot read at all because of neck pain
I can concentrate fully when I want with no difficultyI can concentrate fully when I want with slight difficultyI have a fair degree of difficulty concentrating when I wantI have a lot of difficulty concentrating when I wantI have a great deal of difficulty concentrating when I wantI cannot concentrate at all
I can do as much work as I wantI can only do my usual work but no moreI can only do most of my usual work but no moreI cannot do my usual workI can hardly do any work at allI cannot do any work at all
I can look after myself normally without causing extra painI can look after myself normally but it causes extra painIt is painful to look after myself am I am slow and carefulI need some help but I manage most of my personal careI need help every day in most aspects of self careI do not get dressed, I wash with difficulty and stay in bed
I can lift heavy weights without extra painI can lift heavy weights but it causes extra painPain 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 positionedI can only lift very light weightsI cannot lift or carry anything at all
I can drive my car without any neck painI can drive my car as long as I want wiht slight neck painI can drive my car as long as I want with moderate neck painI cannot drive my car as long as I want because of moderate neck painI can hardly drive at all because of severe neck painI cannot drive my car at all because of neck pain
I am able to engage in all my recreation activities without neck painI am able to engage in all my usual recreation activities with some neck painI am able to engage in most but not all my usual recreation activities because of neck painI am only able to engage in a few of my usual recreation activities because of neck paini can hardly do any recreation activities because of neck painI cannot do any recreation activities at all
I have no headaches at allI have slights headaches which cone infrequentlyI have moderate headaches which come infrequentlyI have moderate headaches which come frequentlyI have severe headaches which come frequentlyI have headaches almost all the time
The Keele Start Back Screening Tool

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UHC Optum Paperwork

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