Neck - Premier Physical Therapy

1. Pain intensity:

0 - I have no pain at the moment

1 - The pain is very mild at this moment.

2 - The pain is moderate at the moment

3 - The pain is fairly severe at the moment.

4 - The pain is very severe at the moment.

5 - The pain is the worst imaginable at the moment.

2. Personal Care (washing, dressing, etc.):

0 - I can look after myself normally without extra pain.

1 - I can look after myself normally but it causes extra pain.

2 - It is painful to look after myself and I am slow and careful.

3 - I need some help but manage most of my personal care.

4 - I need help every day in most aspects of self care.

5 - I cannot get dressed, wash with difficulty, and stay in bed.

3. Lifting:

0 - I can lift heavy weights without extra pain.

1 - I can lift heavy weights but it gives me 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 - I can lift only very light weights.

5 - I cannot lift or carry anything at all.

4. Headache:

0 - I have no headaches at all.

1 - I have slight headaches which come infrequently.

2 - I have moderate headaches which come infrequently.

3 - I have moderate headaches which come frequently.

4 - I have severe headaches which come frequently.

5 - I have headaches almost all the time.

5. Recreation:

0 - I am able to engage in all my recreational activities without pain.

1 - I am able to engage in my recreational activities with some pain.

2 - I am able to engage in most but not all of my usual recreational activities because of my neck pain.

3 - I am able to engage in a few of my usual recreational activities with some neck pain.

4 - I can hardly do any recreational activities because of neck pain.

5 - I can't do any recreational activities at all.

6. Reading:

0 - I can read as much as I want with no pain in my neck.

1 - I can read as much as I want with slight neck pain.

2 - I can read as much as I want with moderate neck pain.

3 - I can't read as much as I want because of neck pain.

4 - I can hardly read at all because of severe neck pain.

5 - I cannot read at all because of neck pain.

7. Work:

0 - I can do as much as I want to.

1 - I can only do my usual work but no more.

2 - I can do most of my usual work but no more.

3 - I cannot do my usual work.

4 - I can hardly do any usual work at all.

5 - I can't do any work at all.

8. Sleeping:

0 - Pain does not prevent me from sleeping well.

1 - My sleep is slightly disturbed (<1 hr sleep loss).

2 - My sleep is mildly disturbed (1-2 hr sleep loss).

3 - My sleep is moderately disturbed (2-3 hr sleep loss).

4 - My sleep is greatly disturbed (3-4 hr sleep loss).

5 - My sleep is completely disturbed (5-7 hr sleep loss).

9. Concentration:

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 concetrating when I want.

5 - I cannot concentrate at all.

10. Driving:

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 pain.

4 - I can hardly drive my car at all because of severe neck pain.

5 - I can't drive my car at all.

Neck / Upper Back
(Assessment)

Please complete the following:

Neck / Upper Back
(Assessment)

Neck / Upper Back (Assessment)

Please complete the following:

Neck / Upper Back (Assessment)

Neck / Upper Back
(Assessment)

Neck / Upper Back
(Assessment)