Neck Outcome Measure

1

Primary Clinic* This field is required.

Boulder

Broomfield

Englewood

Lafayette

Longmont

Wheat Ridge

2

Name* This field is required.

First Name

Last Name

3

Percentage of Disability

4

START Screening Tool (3 or less = low risk)

5

Sub Score (3 or less = medium risk / 4 or more = high risk)

7

Personal Care* This field is required.(washing, dressing etc.)

(0) Normal without extra pain

(1) Normal but causes extra pain

(2) Painful to look after myself and I am slow and careful

(3) Need some help but manage most of my personal care

(4) Need help every day in most aspects of self care

(5) Cannot get dressed, wash with difficulty and stay in bed

8

Lifting* This field is required.

(0) Can lift heavy weights without extra pain

(1) Can lift heavy weights but it causes extra pain

(2) Pain prevents me from lifting heavy weights off the floor but I can manage if they are on a table

(3) Pain prevents me from lifting heavy weights but I can manage if they are conveniently placed

(4) Can lift only very light weights

(5) Cannot lift or carry anything at all

9

Headache* This field is required.

(0) No headaches at all

(1) Slight headaches which come infrequently

(2) Moderate headaches which come infrequently

(3) Moderate headaches which come frequently

(4) Severe headaches which come infrequently

(5) Headaches almost all the time

10

Recreation* This field is required.

(0) Able to engage in all recreational activities without pain

(1) Able to engage in all recreational activities with some pain

(2) Able to engage in most but not all of my usual recreational activities

(3) Able to engage in a few of my usual recreational activities with some neck pain

(4) Hardly able to do any recreational activities because of neck pain

(5) Can't do any recreational activities at all

11

Reading* This field is required.

(0) Can read as much as I want with no pain in my neck

(1) Can read as much as I want with slight neck pain

(2) Can read as much as I want with moderate neck pain

(3) Can't read as much as I want because of moderate neck pain

(4) Can hardly read at all because of severe neck pain

(5) Cannot read at all because of neck pain

12

Work* This field is required.

(0) Can do as much as I want to

(1) Can only do my usual work but no more

(2) Can do most of my usual work but no more

(3) Cannot do my usual work

(4) Can hardly do any usual work at all

(5) Can't do any work at all

13

Sleeping* This field is required.

(0) Pain does not prevent me from sleeping well

(1) My sleep is slightly disturbed (less than one hour sleepless)

(2) My sleep is mildly disturbed (one to two hours sleepless)

(3) My sleep is moderately disturbed (two to three hours sleepless)

(4) My sleep is greatly disturbed (three to five hours sleepless)

(5) My sleep is completely disturbed (five to seven hours sleepless)

14

Concentration* This field is required.

(0) I can concentrate fully when I want with no difficulty

(1) I can concentrate fully when I want with slight difficulty

(2) I have a fair degree of difficulty concentrating when I want

(3) I have a lot of difficulty concentrating when I want

(4) I have great difficulty concentrating when I want

(5) I cannot concentrate at all

15

Driving* This field is required.

(0) I can drive my car without neck pain

(1) I can drive my car as long as I want with slight neck pain

(2) I can drive my car as long as I want with moderate neck pain

(3) I can't drive my car as long as I want because of moderate neck pain

(4) I can hardly drive my car at all because of severe neck pain

(5) I can't drive my car at all

16

Has your neck pain spread down your arm(s) at some point in the past two weeks?* This field is required.

Yes (1)

No (0)

17

Have you had pain in the low back at some point in the past two weeks?* This field is required.

Yes (1)

No (0)

18

Have you only walked short distances because of your neck pain?* This field is required.

Yes (1)

No (0)

19

In the last two weeks, have you dressed more slowly because of your neck pain?* This field is required.

Yes (1)

No (0)

20

Do you think it's not really safe for a person with a condition like yours to be physically active?* This field is required.

Yes (1)

No (1)

21

Have worrying thoughts been going through your mind a lot of the time?* This field is required.

Yes (1)

No (1)

22

Do you feel that your neck pain is terrible and it's never going to get any better?* This field is required.

Yes (1)

No (0)

23

In general have you stopped enjoying all the things you normally enjoy?* This field is required.

Yes (1)

No (0)

24

Overall how bothersome has your neck pain been in the past two weeks?* This field is required.

Not at all (0)

Slightly (0)

Moderately (0)

Very Much (1)

Extremely (1)