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.
Email*
example@example.com
Occupation*
Next of Kin*
Name
Contact Number*
Please enter a valid phone number.
Referring doctor:*
Name
Contact Number*
Please enter a valid phone number.
Marital status:

SinglePartneredMarriedSeparatedDivorcedWidowed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Usual GP:*
Name
Contact Number*
Please enter a valid phone number.
Medicare
Position
Expiry Date
Private Health
Veterans Affairs
Card Colour
WORKERS COMPENSATION / THIRD PARTY DETAILS
Are you claiming workers compensation? *

YesNo
Claim Number
Are you claiming workers compensation? *

YesNo
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.
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:

------
□□□□
○○○○
∆∆∆∆
xxxx

Numbness
Pins and needles
Burning pain
Stabbing pain
Aching pain

Is your pain as a result of an injury?*

YesNo
(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 ?*

YesNo
If yes please describe the weakness
Does keeping your hand on your head relieve the arm pain?*

YesNo
What is worse - neck or arm pain?
Neck pain percentage (%)*
Arm pain percentage (%)*
Has your hand grip weakened?*

YesNo
Are you dropping things?*

YesNo
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?*

YesNo
Are you able to look after yourself?*

YesNo
Are you able to do most of your work?*

YesNo
Are you recreational activities being affected?*

YesNo
Which activities are most affected
Is your problem getting:*

ImprovingWorseningStatic
Do you have problems in any other joint?*

YesNo
If Yes, has it been diagnosed Rheumatoid , Osteoarthritis or some other named disease? Which other Joints are involved?
Have you lost appetite recently? *

YesNo
Have you lost appetite recently? *

YesNo
Have lost weight recently? *

YesNo
How much? Is it intentional or unexplained?
Are you having fevers, hot sweats or chills?*

YesNo
Have you been diagnosed or treated for any cancer? *

YesNo
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?*

YesNo
Have you had any spine surgery before?*

YesNo
Please describe if you know what was the surgery?*
Is there any legal case pending?*

YesNo
Do you smoke?*

YesNo
How long you have been smoking and how many you smoke per day ?
Do you drink alcohol?*

YesNo
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?*

GP advise the specialist opinionYou wanted to see a specialist and learn more about the cause and management of the pain.You have been advised surgery but you would like to discuss the other optionsYou have tried everything else and would like to discuss and consider whether surgery is indicated or not
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*

I have no pain at the moment.The pain is very mild at the moment.The pain is moderate at the moment.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.
SECTION 6 – CONCENTRATION*

I can concentrate fully without difficulty.I can concentrate fully with slight difficulty.I have a fair degree of difficulty concentrating.I have a lot of difficulty concentrating.I have a great deal of difficulty concentrating.I can't concentrate at all.
SECTION 2 - 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, and I am slow and careful.I need some help but manage most of my personal careI need help every day in most aspects of self -care.I do not get dressed. I wash with difficulty and stay in bed.
SECTION 7 – SLEEPING*

I have no trouble sleeping.My sleep is slightly disturbed for less than 1 hour.My sleep is mildly disturbed for up to 1-2 hours.My sleep is moderately disturbed for up to 2-3 hours.My sleep is greatly disturbed for up to 3-5 hours.My sleep is completely disturbed for up to 5-7 hours.
SECTION 3 – LIFTING*

I can lift heavy weights without causing extra pain.I can lift heavy weights, but it gives me extra pain.Pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie. on a table.Pain prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positioned.I can lift only very light weights.I cannot lift or carry anything at all.
SECTION 8 – DRIVING*

I can drive my car without neck pain.I can drive as long as I want with slight neck pain.I can drive as long as I want with moderate neck pain.I can't drive as long as I want because of moderate neck pain.I can hardly drive at all because of severe neck pain.I can't drive my care at all because of neck pain.
SECTION 4 – WORK*

I can do as much work as I want.I can only do my usual work, but no more.I can do most of my usual work, but no more.I can't do my usual work.I can hardly do any work at all.I can't do any work at all.
SECTION 9 – 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 can't read as much as I want because of moderate neck pain.I can't read as much as I want because of severe neck pain.I can't read at all.
SECTION 5 – HEADACHES*

I have no headaches at all.I have slight headaches that come infrequently.I have moderate headaches that come infrequently.I have moderate headaches that come frequently.I have severe headaches that come frequently.I have headaches almost all the time.
SECTION 10 – RECREATION*

I have no neck pain during all recreational activities.I have some neck pain with all recreational activities.I have some neck pain with a few recreational activities.I have neck pain with most recreational activities.I can hardly do recreational activities due to neck pain.I can't do any recreational activities due to neck pain.
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Neck Pain Questionnaire

WORKERS COMPENSATION / THIRD PARTY DETAILS

Questionnaire

What is worse - neck or arm pain?

NECK DISABILITY INDEX