Please complete this form prior to your consultation. The information will help us in determining a diagnosis and treatment. Please note that all information is kept strictly confidential and will not be disclosed to any third parties. Personal DetailsName * Address * Contact Phone * Email * Who referred you to us ie GP, Therapist, Friend ? Regarding you Neck pain ;Is it worse on one side of the spine ? *YesNo Does your neck feel stiff in the mornings but gets better after a while ? NoYes Is the pain worse at the end of the day or when you sit for long periods in front of a computer ? ? NoYes Is pain is worse after impact sports such as tennis or football ? YesNo Does pain refer into one or both arms below the shoulders ? NoOne leg onyYes both legs Is there weakness in one or both arms ? Weakness in one armWeakness in both armsNo weakness in arms Is there numbness in one or both arms ? No Numbness in armsOne armBoth arms How long have you had these symptoms *Less than 2 weeks2 - 6 weeks6 weeks to 6 monthsLonger than 6 months Is pain is better when you lie down ? YesNo Do you have any problems in controlling bowels or urine ? *No - Bowels and Bladder are working fineYes - Loss of functional control Functional Assessment ScoreNeck Disability Questionnaire This questionnaire has been designed to give us information about the severity of your neck pain. Please answer every question by selecting the answer that best describes your condition today. We realise you may feel that two of the statements may describe your condition, but please select only the single answer which most closely describes your current condition. Section 1 - Pain Intensity *0 I have no pain at the moment.1 The pain is very mild at the 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 worse imaginable at the moment. Section 2 – Personal Care (Washing, dressing, etc.) 0. I can look after myself normally without causing extra pain.1. I can look after myself normally but it causes me extra pain.2 It is painful to look after myself and I am slow and careful.3. I need some help but can manage most of my personal care4. I need help every day in most aspects of self care5. I do not get dressed, wash with difficulty and stay in bed. Section 3 – Lifting *0. I can lift heavy weights without extra pain.1. I can lift heavy weights but it gives extra pain.2. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned for example on a table.3. Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned4. I can only lift very light weights5. I cannot lift or carry anything at all. Section 4 – Reading *0 I can read as much as I want to with no pain in my neck.1 I can read as much as I want to with slight pain in my neck.2 I can read as much as I want with moderate pain in my neck.3 I can’t read as much as I want because of moderate pain in my neck.4 I can hardly read at all because of severe pain in my neck.5 I cannot read at all due to my neck pain Section 5 – Headache *0 I have no headache 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 Concentration *0. I can concentrate fully when I want to with no difficulty1. I can concentrate fully when I want to with slight difficulty2. I have a fair degree of difficulty in concentrating when I want to3. I have a lot of difficulty in concentrating when I want to4. I have a great deal of difficulty in concentrating when I want to5. I cannot concentrate at all Work *0. I can do as much work as I want to1. I can only do my usual work, but no more2. I can do most of my usual work, but no more3. I cannot do my usual work4. I can hardly do any work at all5. I can’t do any work at all Driving *0. I can drive my car without any neck pain1. I can drive my car as long as I want with slight pain in my neck2. I can drive my car as long as I want with moderate pain in my neck3. I can't drive my car as long as I want because of moderate pain in my neck4. I can hardly drive at all because of severe pain in my neck5. I can’t drive my car at all Sleeping *0. I have no trouble sleeping1. My sleep is slightly disturbed (less than 1 hr sleepless)2. My sleep is mildly disturbed (1-2 hrs sleepless)3. My sleep is moderately disturbed (2-3 hrs sleepless)4. My sleep is greatly disturbed (3-5 hrs sleepless)5. My sleep is completely disturbed (5-7 hrs sleepless) Recreation *0. I am able to engage in all my recreation activities with no neck pain at all1. I am able to engage in all my recreation activities, with some pain in my neck2. I am able to engage in most, but not all of my usual recreation activities because of pain in my neck3. I am able to engage in a few of my usual recreation activities because of pain in my neck4. I can hardly do any recreation activities because of pain in my neck5. I can’t do any recreation activities at all Visual Analogue ScoresPain Intensity - Please estimate how intense your pain is now 0. No Pain1345678910. Worst possible pain2345678910. Worst possibe pain Average pain intensity - please estimate your average pain over the last week 0. No Pain12345678910. Worst possible pain Distress-Estimate how distressing your problem has been over last week: 0. No Distress12345678910. Totally distressing Coping-Please estimate how confident you feel at coping witha flare up 0. Totally Confident12345678910. No Confidence VerificationPlease enter two digits with no spaces (Example: 12) *This box is for spam protection - please leave it blank Like
