Neck Survey-Chapman

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Neck Pre-Exam Form
Chapman Location

For Patients experiencing any kind of neck injury/pain. Please fill out to the best of your ability and submit.

** This survey is meant to help us obtain information from you regarding your current levels of discomfort and capability.

* Indicates required field

Name *

First

Last

PLEASE RATE YOUR PAIN LEVEL WITH ACTIVITY *

0 - No Pain 1 - Minimal - hardly noticeable 2-Mild - aware of pain but don't pay attention to it 3-Uncomfortable - bothers me but I can ignore it 4-Moderate - Constantly aware but can continue most activities 5-Distracting - Constantly aware and keeping me from doing some activities 6 - Distressing - Constantly aware of pain and I give up many activities. 7-Unmanageable - In pain all the time and unable to do most activities 8-Intense - Pain is so severe that it is hard to think of anything else. Talking & listening are difficult 9-Severe - My pain is all I can think about. I can barely talk or move because of it. 10-Unable to Move - In bed and can't move due to my pain. I need to go to the emergency room.

On the following, please mark the most appropriate response about your pain level with the following activities *

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 worse imaginable at the moment

2. PERSONAL CARE (washing, dressing, etc.) *

I can look after myself normally without extra pain I can look after myself normally 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 cannot get dressed, wash with difficulty and stay in bed

3. LIFTING *

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 on a table. Pain prevents me from lifting heavy weights but I can manage if they are conveniently placed. I can lift only very light weights. I cannot lift or carry anything at all.

4. HEADACHE *

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 infrequently. I have headaches almost all the time.

5. RECREATION *

I am able to engage in all my recreational activities without pain. I am able to engage in my recreational activities with some pain. I am able to engage in most but not all of my usual recreational activities because of my neck pain I am able to engage in a few of my usual recreational activities with some neck pain. I can hardly do any recreational activities because of neck pain I can't do any recreational activities at all.

6. READING *

I can read as much as I want with no pain in my neck. 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 rad at all because of severe neck pain. I cannot read at all because of neck pain.

7. WORK *

I can do as much 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 usual work at all. I can't do any work at all.

8. SLEEPING *

Pain does not prevent me from sleeping well. My sleep is slightly disturbed (< 1 hr sleep loss). My sleep is mildly disturbed (1-2 hr sleep loss). My sleep is moderately disturbed (2-3 hr sleep loss). My sleep is greatly disturbed (3-4 hr sleep loss). My sleep is completely disturbed (5-7 hr sleep loss).

9. CONCENTRATION *

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. I have a lot of difficulty concentrating when I want. I have great difficulty concentrating when I want. I cannot concentrate at all.

10. DRIVING *

I can drive my car without 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 my car at all because of severe neck pain. I can't drive my car at all.

Submit

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.

Now with 2 Locations to Better Serve You!

ABILENE:
103 Northwest 15th Street
Abilene, KS 67410
Phone: 785-263-3646
FAX: 785-263-3689

HOURS:
Monday - Friday
8 a.m. - 5 p.m.

CHAPMAN:
1030 North Marshall, Suite B
Chapman, KS 67431
Phone: 785-922-4016
FAX: 785-922-4018

HOURS:
Monday - Friday
8 a.m. - 5 p.m.

** This survey is meant to help us obtain information from you regarding your current levels of discomfort and capability.

The state of Kansas is a “Direct Access” state for Physical Therapy. ​ You can begin physical therapy with or without a referral from a physician. ​

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.