Cleveland Biophysics - Neck and Back Questionaire

Office Hours:

Monday:

9:00a - 12:30p
3:00p - 6:30p

Tuesday:

3:00p - 6:30p

Wednesday:

9:00a - 12:30p
3:00p - 6:30p

Thursday:

3:00p - 6:30p

Friday:

9:00a - 12:30p

Saturday:

8:30a - 11:00a

Neck & Upper Back Function Questionnaire
Curious to see if your health problems are affecting your daily life? The following 10 questions are the most proven way to answer that question.
Simply click one answer that best fits. If 2 choices fit, pick the worst. Each question must be answered.

Section 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.	Section 6- Concentration I can concentrate fully when I want to with no difficulty. I can concentrate fully when I want to with slight difficulty. I have a fair degree of difficulty concentrating when I want. I have a lot of difficulty concentrating when I want to. I have a great deal of difficult concentrating when I want to. I cannot concentrate at all.

Section 2- Personal Care (Washing, Dressing, etc.) I can look after myself normally without causing extra pain. I can look after myself normally, but it causes some 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 everyday in most aspects of self care. I do not get dressed; I wash with difficulty and stay in bed	Section 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 cannot do any work at all.

Section 3- Lifting I can lift heavy weights without extra pain. I can lift heavy weights, but it gives extra pain. Pain prevents me from lifting weights off of the floor. Pain prevents heavy lifting, but not light to medium weight. I can lift very light weights. I can not lift or carry anything at all.	Section 8- Driving 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 cannot drive my car as long as I want due to moderate neck pain. I can hardly drive at all because of severe neck pain. I cannot drive my car at all.

Section 4- Reading I can read as much as I want to with no pain in my neck. I can read as much as I want to with slight pain in my neck. I can read as much as I want to with moderate neck pain. I cannot read as much as I want due to moderate neck pain. I cannot read as much I want due to severe neck pain. I cannot read at all.	Section 9- Sleeping I have no trouble sleeping. My sleep is slightly disturbed ( <1 hour sleeplessness) My sleep is mildly disturbed (1-2 hours of sleeplessness) My sleep is moderately disturbed (2-3 hours sleeplessness) My sleep is greatly disturbed (3-5 hours of sleeplessness) My sleep is completely disturbed (5-7 hours sleeplessness)

Section 5- Headaches I have no headaches at all. I have slight headaches which come infrequently. I have moderate headaches which come infrequently. I have moderate headaches which come frequently. I have severe headaches which come frequently. I have headaches almost all of the time.	Section 10- Recreation I am able to engage in all of my activities with no neck pain. I am able to engage in all of my activities with some neck pain. I am able to engage in most, but not all activities due to neck pain. I am able to engage in only a few activities due to neck pain. I can hardly engage in any activities due to neck pain. I can not engage in any activities due to neck pain.

Cleveland Biophysics, LLC
7050 Engle Rd.
Suite 101
Middleburg Heights, OH 44130

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