Follow-Up Form for Return Visits with Dr. LaMotta only

Name

First NameLast Name

Date of Birth

Date

Appointment Date

Date

Chart Number

On a scale of 1-10, rate the average level of pain in your back and/or neck:

On a scale of 1-10, rate the average level of pain in your leg and/or arm:

Since your last visit, how would you rate your improvement? Please select the appropriate percentages with 0% being no improvement and 100% being no pain.

This questionaire has been designed to give the doctor information on how your back pain has affected your ability to manage everyday life. Please answer every section, and mark in each section only the one answer that applies to you. We realize you may consider that two of the statements in any one section relate to you, but please check just one which most closely describes your problem.

Section 1 - Pain Intensity

I can tolerate the pain I have without having to use painkillers.The pain is bad but I manage without taking painkillers.Painkillers give complete relief from pain.Painkillers give moderate relief from pain.Painkillers give very little relief from pain.Painkillers have no effect on the pain and I do not use them.

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 but I am slow and careful.I need some help but manage most of my personal care.I need some help everyday in most aspects of selfcare.I do not get dressed, wash with difficulty, and stay in bed.

Section 3 - Lifting

I can lift heavy weights without causing 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 positioned, e.g. 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 only very light weights.I cannot lift or carry anything at all.

Section 4 - Walking

Pain does not prevent me from walking any distance.Pain prevents me from walking more than 1 mile.Pain prevents me from walking more that 1/2 mile.Pain prevents me from walking more that 1/4 mile.I can only walk using a stick/cane or crutches.I am in bed most of the time and have to crawl to the toilet.

Section 5 - Sitting

I can sit still 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 an hour.Pain prevents me from sitting more that 1/2 hour.Pain prevents me from sitting more that 10 minutes.Pain prevents me from sitting at all.

Section 6 - Standing

I can stand as long as I want without extra pain.I can stand as long as I want but it gives me extra pain.Pain prevents me from standing more than 1 hour.Pain prevents me from standing more than 30 minutes.Pain prevents me from standing more than 10 minutes.Pain prevents me from standing at all.

Section 7 - Sleeping

Pain does not prevent me from sleeping at all.I can sleep well only by using tablets.Even when I take tablets, I have less than 6 hours sleep.Even when I take tablets, I have less than 4 hours sleep.Even when I take tablets, I have less than 2 hours sleep.Pain prevents me from sleeping at all.

Section 8 - Sex Life

My sex life is normal and causes no extra pain.My sex life is normal but causes some extra pain.My sex life is nearly normal but is very painful.My sex life is severely restricted by pain.My sex life is nearly absent because of pain.Pain prevents any sex life at all.

Section 9 - Social Life

My social life is normal and gives no extra pain.My social life is normal but increases the degree of pain.Pain has no significant effect on my social life apart from limiting my more energetic interest, e.g. dancing, etc.Pain has restricted my social life and I do not go out as often.Pain has restricted my social life to my home.I have no social life because of pain.

Section 10 - Traveling

I can travel anywhere without extra pain.I can travel anywhere but it gives me extra pain.Pain is bad but I can manage journeys over 2 hours.Pain restricts me to journeys less than 1 hour.Pain restricts me to short, necessary journeys of less than 1 hour.Pain prevents me from traveling except to the doctor or hospital.

Date