3D Spine Simulator


Launch 3D Spine Simulator

Please print & bring this questionaire with you to your visit to find out & discuss your score with our practitioners.
 
Please check off the choice that best describes your Neck Pain.

 

1 - Pain Intensity
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 imaginable at the moment.

2 - Personal Care (Washing, Dressing, etc.)
I can look after myself normally without causing extra pain.
I can look after myself normally but it caused 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 wash with difficulty and stay in bed.

3 - Lifting
I can lift heavy weight without extra pain.
I can lift heavy weights but it gives extra pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (on a table etc.).
I can lift light to moderate weights.
I can lift very light weights.
I cannot lift or carry anything at all.

4 - Reading
I can read as much as I want to without pain in my neck.
I can read as much as I want with slight pain in my neck.
I can read as much as I want with moderate pain.
I can't read as much as I want because of moderate pain in my neck.
I can hardly read at all because of severe pain in my neck.
I cannot read at all because of pain in my neck.

5 - Headaches
I have no headaches at all.
I have slight headaches, which come infrequently.
I have slight headaches, which come frequently.
I have moderate headaches, which come infrequently.
I have severe headaches, which come frequently.
I have headaches almost all the time.

6 - Concentration
I can concentrate fully when I want to without difficulty.
I can concentrate fully when I want to with slight difficulty.
I have a fair degree of difficulty in concentrating when I want to.
I have lot of difficulty in concentrating when I want to.
I have a great deal of difficulty in concentrating when I want to.
I cannot concentrate at all.

7 - Work
I can do as much work as I want to.
I can only 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 can't do work at all.

8 - Driving
I can drive my car without any neck pain.
I can drive my car as long as I want with slight pain in my neck.
I can drive my car as long as I want with moderate pain.
I can't drive my car as long as I want because of moderate pain in my neck.
I can hardly drive my car as long as I want because of severe pain in my neck.
I can't drive my car at all.

9 - Sleeping
I have no trouble sleeping.
My sleep is slightly disturbed (less than one hr. sleepless).
My sleep is moderately disturbed ( 1-2 hrs. sleepless).
My sleep is moderately disturbed ( 3-4 hrs. sleepless).
My sleep is greatly disturbed (4-5hrs. sleepless).
My sleep is completely disturbed ( 5-7 hrs. sleepless).

10 - Changing Degree of Pain
I am able to engage in all my recreational activities with no neck pain at all.
I am able to engage in all my recreational activities with some neck pain.
I am able to engage in most, but not all of my usual recreational activities because of pain in my neck.
I am able to engage in a few of my usual recreational activities because of pain in my neck.
I can hardly do any recreational activities because of pain in my neck.
I can't do any recreational activities at all.