OPTUM QUESTIONNAIRE

OPTUM QUESTIONNAIRE
Full Name/Participant’s Name:*

First NameLast Name
Email*
example@example.com
Symptoms began on:

MonthDayYear
Date
Briefly describe your symptoms
How did your symptoms start?
Average pain / symptom intensity:

no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain
Last 24 hours

12345678910
Past week

12345678910
How often do you experience your symptoms?

Constantly (76% to 100% of the time)Frequently (51% - 75% of the timeOccasionally (26% - 50% of time)Intermittently (0% - 25% of the time)
How much have your symptoms interfered with your daily activities?

Not at allA little bitModeratelyQuite a bitExtremely
How is your condition changing, since care at this facility?

N/A - this is the initial visitMuch worseWorseA little worseNo changeA little betterBetterMuch better
In general, would you say your overall health right now is...

ExcellentVery goodGoodFairPoor
Back Screening Tool (if applicable)
Annotate Image
Has your back pain spread down your leg(s) at some time in the last 2 weeks?

YesNo
Have you had pain in the shoulder or neck at some time in the last 2 weeks?

YesNo
Have you only walked short distances because of your back pain?

YesNo
In the last 2 weeks, have you dressed more slowly than usual because of back pain?

YesNo
Do you think it’s not really safe for a person with a condition like your to be physically active?

YesNo
Have worrying thoughts been going through your mind a lot of time?

YesNo
Do you feel that your back pain is terrible and its never going to get any better?

YesNo
In general, have you stopped enjoying all the things you usually enjoy?

YesNo
Overall, how bothersome has your back pain been in the last 2 weeks?

Not at allSlightlyModeratelyVery muchExtremely
Date*

MonthDayYear
Date
Patient Signature:*

Clear
Please affix your signature inside the box

p. 443.979.7171

AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170 Columbia, MD 21046

f. 667.200.5908