Self-assessment surveys - Pages

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This questionaire is designed to give information as to how your neck pain has affected your ability to manage in your everyday life.

Please choose one of the options

Please, pick the answer that most accurately describes your problem today.

Please choose one of the options

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Pain intensity:

Please choose one of the options

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 pain imaginable at the moment

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Personal care (e.g. washing, dressing, etc.):

Please choose one of the options

I can look after myself normally, without causing extra pain

I can look after myself, 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 care

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

I do not get dressed; I was with difficulty and stay in bed

5 / 12

Lifting:

Please choose one of the options

I can lift heavy weights without 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 they are conveniently positioned (like on a table)

Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned

I can lift very light weights

I cannot lift or carry anything at all

6 / 12

Reading:

Please choose one of the options

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 hardly read at all because of severe pain in my neck

I cannot read at all

7 / 12

Headaches:

Please choose one of the options

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

8 / 12

Concentration:

Please choose one of the options

I can concentrate fully when I want with no difficulty

I can concentrate fully when I want with slight difficulty

I have a fair degree of difficulty concentrating when I want to

I have a lot of difficulty concentrating when I want to

I have a great deal of difficulty concentrating when I want to

I cannot concentrate at all

9 / 12

Work:

Please choose one of the options

I can do as much work as I want

I can do my usual work but no more

I can do most of my usual work, but no more

I cannot do my usual work

I can hardly do any work at all

I cannot do any work at all

10 / 12

Driving:

Please choose one of the options

I can drive my car without any neck pain

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

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

I can't drive my car 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 a car at all

11 / 12

Sleeping:

Please choose one of the options

I have no trouble sleeping

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

My sleep is mildly disturbed (1 to 2 hours sleepless)

My sleep is moderately disturbed ( 2 to 3 hours sleepless)

My sleep is greatly disturbed (3 to 5 hours sleepless)

My sleep is completely disturbed (5 to 7 hours sleepless)

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Recreation:

Please choose one of the options

I am able to engage in all my recreation activities with no neck pain

I am able to engage in all my recreation activities with some neck pain

I am able to engage in most, but not all, of my usual recreation activities because of neck pain

I am able to engage in a few of my usual recreation activities because of neck pain

I can hardly do any recreation activities because of neck pain

I can't do any recreation activities at all because of neck pain