Neck Pain Questionnaire

Neck Pain Questionnaire

Personal Details
Name
Date of Birth

MonthDayYear
Telephone Number

Area CodePhone Number
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Occupation
Next of Kin
Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring doctor:
Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Marital status:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Usual GP:
Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Medicare
Position
Expiry Date
Private Health
Veterans Affairs
Card Colour
WORKERS COMPENSATION / THIRD PARTY DETAILS
Are you claiming workers compensation?
Claim Number
Are you claiming workers compensation?
Policy Number
Employers Name
Employers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name
Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company
Date of Injury

MonthDayYear
Date
Questionnaire
Neck pain intensity
Worst Number*   /10
Best Number*   /10
On average Number*   /10
Arm pain intensity
Worst *   /10
Best *   /10
On average *   /10

Please tick the characteristic of your pain and draw or shade the pain area in the cartoon below:

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xxxx

Numbness
Pins and needles
Burning pain
Stabbing pain
Aching pain

Is your pain as a result of an injury?
(If Work cover or Motor accident claim please fill up the accompanying injury form) Otherwise Please describe the injury here:
Have you had neck or arm pain before? If yes, please describe the-duration, number of episodes, treatments and their effectiveness?
Which activities trigger or aggravates the pain?
Which relieves or lessens the pain?
Do you feel weakness in arms, hands or legs ?
If yes please describe the weakness
Does keeping your hand on your head relieve the arm pain?
What is worse - neck or arm pain?
Neck pain percentage (%)
Arm pain percentage (%)
Has your hand grip weakened?
Are you dropping things?
Have you noticed changes in your hand functions - buttoning, handwriting or other fine motor skills, what bowel or bladder problems, if any, have you noticed?
Are you able to drive?
Are you able to look after yourself?
Are you able to do most of your work?
Are you recreational activities being affected?
Which activities are most affected
Is your problem getting:
Do you have problems in any other joint?
If Yes, has it been diagnosed Rheumatoid , Osteoarthritis or some other named disease? Which other Joints are involved?
Have you lost appetite recently?
Have you lost appetite recently?
Have lost weight recently?
How much? Is it intentional or unexplained?
Are you having fevers, hot sweats or chills?
Have you been diagnosed or treated for any cancer?
If yes, please summarise or tell me during the consultation
What pain medications do you take? How long have you been taking these? What treatments have you tried so far?
Do you think or have you been told you need surgery?
Have you had any spine surgery before?
Please describe if you know what was the surgery?
Is there any legal case pending?
Do you smoke?
How long you have been smoking and how many you smoke per day ?
Do you drink alcohol?
If yes, how many standard drinks per week?
What level of physical fitness activities do you do?
What’s the reason for making this appointment?
Is there anything special you would like to discuss or ask today?
NECK DISABILITY INDEX

THIS QUESTIONNAIRE IS DESIGNED TO HELP US BETTER UNDERSTAND HOW YOUR NECK PAIN AFFECTS YOUR ABILITY TO MANAGE EVERYDAY-LIFE ACTIVITIES. PLEASE MARK IN EACH SECTION THE ONE BOX THAT APPLIES TO YOU. ALTHOUGH YOU MAY CONSIDER THAT TWO OF THE STATEMENTS IN ANY ONE SECTION RELATE TO YOU,PLEASE MARK THE BOX THAT MOST CLOSELY DESCRIBES YOUR PRESENT-DAY SITUATION.
SECTION 1 - PAIN INTENSITY
SECTION 6 – CONCENTRATION
SECTION 2 - PERSONAL CARE
SECTION 7 – SLEEPING
SECTION 3 – LIFTING
SECTION 8 – DRIVING
SECTION 4 – WORK
SECTION 9 – READING
SECTION 5 – HEADACHES
SECTION 10 – RECREATION
Signature
Date

MonthDayYear
Please verify that you are human
Should be Empty:

Neck Pain Questionnaire

WORKERS COMPENSATION / THIRD PARTY DETAILS

Questionnaire

What is worse - neck or arm pain?

NECK DISABILITY INDEX