Final Visit Outcome Questionnaire

Final Visit Outcome Questionnaire - Acupuncture Care
Name

First NameLast Name
This questionnaire helps document how acupuncture care has affected your pain, function, daily activities, and overall well-being.
Current pain level (what is your pain level right now)

No pain – I am not experiencing any pain at this timMinimal pain – Pain is present but is annoying only and does not limit my regular activitiesMild pain – I can usually work through the pain, but I sometimes need to change the way I do certain activitiesModerate pain – I can tolerate the pain, but I often must change the way I do activities and sometimes cannot perform them at allSevere pain – The pain is so intense that I cannot do most activities; getting around the house is difficult and my quality of life is significantly affectedOther
How often do you experience pain:

Occasional – My pain only occurs with certain acitivitiesIntermittent – Pain comes and goes throughout the day, depending on activityFrequent – Pain occurs approximately 75 percent of the timeConstant – Pain occurs 90 to 100 percent of the timeOther
What do you take to manage your pain

Acetaminophen (Tylenol)OTC NSAIDs (ibuprofen, naproxen, aspirin)Prescription NSAIDs (meloxicam, diclofenac, celecoxib)Opioid or narcotic pain medications (Tramadol, Hydrocodone, CodOxycodone, Morphine)Topical pain medications (such as Diclofenac gel, Lidocaine patches or cream)Pregabalin (Lyrica)Duloxetine (Cymbalta)Muscle relaxers (cyclobenzaprine, tizanidine, baclofen)I do not take any medications for painOther
Medication Use Since Starting Acupuncture

I am able to use lower doses of pain medication to manage my painReduced need for breakthrough medicationI am able to delay taking pain medication longer than beforeI no longer requires medicationI require the same amount of pain medication to manage my painOther
Duration of Pain Relief After Acupuncture

I get several hours of relief following acupuncture1-2 days3-7 daysOne week or longerMy pain levels have steadily decreasedRelief variesOther
Functional Improvements in daily activities - Check all that apply

Improved tolerance for activity before pain increasesPain flares occur less oftenPain is easier to calm once it startsPain flares are shorter in durationImproved ability to pace activities without triggering significant symptom worseningFaster recovery after activityAble to stay active longer before needing restImproved range of motion during daily activitiesImproved ability to manage chronic symptomsImproved balance or stabilityLess muscle tensionLess headaches/migrainesHeadaches/migraines are less intense when they occurHeadaches/migraines are shorter in duration when they occurReduced guarding or protective movementsImproved posture or ability to maintain posture longerImproved tolerance to prolonged standing (standing in place, waiting in line, standing at the sink) I can stand longer and with less painImproved tolerance to prolonged sitting (sitting at a desk, watching TV, riding in a car)Less stiffness after sitting or inactivityImproved ability to complete tasks in one attempt rather than breaking them upWalking (walking short distances, walking longer distances, walking on uneven ground)Stairs (going up or down stairs, steps, or curbs) are easier and less painfulBending or stooping (bending to pick items up, tying shoes, cleaning low areas, reaching low cabinets) is easier and less painfulPush or pull (pushing a door, pulling a cart, vacuuming, opening heavy doors)Yard work (mowing the lawn, weeding, raking, etc.)Getting in or out of a chair (rising from a chair, sitting down, getting off a couch)Showering or bathing (standing in the shower, washing, stepping in or out of tub)Dressing my lower body (putting on or taking off shoes, socks, pants, underwear)Dressing my upper body (putting on or taking off shirt and/or bra)Lift or carry (lifting groceries, carrying laundry, lifting household items)Grocery shopping (walking store aisles, reaching shelves, carrying bags)Loading or unloading a vehicle (lifting items into or out of a car or truck, loading groceries, moving equipment)General lifting (lifting objects of various weights; although pain may still be present, lifting feels easier and or heavier items can be lifted than before)Household chores (cleaning, cooking, laundry, making the bed) are easier and less painfulDriving short distances (driving locally, short errands)Driving long distances (longer trips, highway driving, trips more than one hour)Traveling (sitting for long periods, walking through airports, lifting or carrying luggage, getting in and out of vehicles)Reaching overhead (reaching into cabinets, putting items on shelves)Turning head or body (checking blind spots, turning to look behind)Sleeping (falling asleep, staying asleep, changing positions)Less stiffness upon waking after sleepI am getting out of the house more (leaving home, attending appointments, running errands)Socializing (spending time with family or friends, attending events)Work or usual duties (job tasks, volunteering, daily responsibilities) are easier due to less painImproved work tolerance or productivityFewer missed workdays or activity daysLifting or carrying a child (picking up a child, holding a child, lifting into or out of a car seat or stroller)Playing with children (getting on and off the floor, bending, reaching, active play)Caring for a pet (walking a dog, feeding, grooming, cleaning up after a pet)Lifting or carrying a pet (lifting a small pet, assisting an older or injured pet, loading into a vehicle)Hobbies (gardening, woodworking, crafts, DIY projects, recreational activities)Sports or recreational sports (golf, pickleball, tennis, basketball, softball, recreational leagues)Workouts or exercise (gym workouts, weight training, resistance exercises, fitness classes)Running or jogging (running, jogging, treadmill running, interval training)Improved quality of life despite ongoing symptomsOther
Other improvements during course of acupuncture. Select all that apply

Improved moodLess anxietyPanic attacks (fewer or less intense)PTSD is more managableFeeling more motivatedBetter family or work relations due to imporved moodImproved energy levelsImproved sleep qualityImproved digestionOther

Final Visit Outcome Questionnaire - Acupuncture Care

Overall Quality of Life Change