Please check the one box in each section
that most closely describes your condition.
|
Section 1- Pain Intensity |
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I have no pain at the moment. |
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The pain is very mild at the moment. |
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The pain is moderate at the moment. |
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The pain is fairly severe at the moment. |
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The pain is very severe at the moment. |
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The pain is the worst imaginable at the moment. |
|
Section 2- Personal Care (Washing, Dressing
etc.) |
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I can look after myself normally without causing extra
pain. |
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I can look after myself normally but it causes extra
pain. |
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It is painful to look after myself and I am slow and
careful. |
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I need some help but manage most of my personal care. |
| |
I need help every day in most aspects of self care. |
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I do not get dressed, I wash with difficulty and stay in
bed. |
|
Section 3- Lifting |
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I can lift heavy weights without extra pain. |
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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, for example
on a table. |
| |
Pain prevents me from lifting heavy weights off the floor,
but I can manage light to medium weights if they are
conveniently positioned. |
| |
I can lift very light weights. |
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I cannot lift or carry anything at all. |
|
Section 4- Reading |
| |
I can read as much as I want to with no pain in my
neck. |
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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 pain in my
neck. |
| |
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 my
neck. |
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I cannot read at all. |
|
Section 5- Headaches |
|
|
I have no headaches at all. |
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I have slight headaches which come in-frequently. |
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I have moderate headaches which come in-frequently. |
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I have moderate headaches which come frequently. |
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I have severe headaches which come frequently. |
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I have headaches almost all the time. |
|
Section 6-
Concentration |
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I can concentrate fully when I want to with no
difficulty. |
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I can concentrate fully when I want to with slight
difficulty. |
| |
I have a fair degree of difficulty in concentration when I
want to. |
| |
I have a lot of difficulty in concentrating when I want
to. |
| |
I have a great deal of difficulty in concentrating when I
want to. |
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I cannot concentrate at all. |
|
Section 7- Work |
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I can do as much work as I want to. |
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I can only do my usual work, but no more. |
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I can do most of my usual work, but no more. |
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I cannot do my usual work. |
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I can hardly do any work at all. |
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I can't do any work at all. |
|
Section 8- Driving |
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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
pain in my neck. |
| |
I can hardly drive at all because of severe pain in my
neck. |
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I can't drive my car at all. |
|
Section 9- Sleeping |
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I have no trouble sleeping. |
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My sleep is slightly disturbed (less than 1 hour
sleepless). |
| |
My sleep is mildly disturbed ( 1-2 hours sleepless). |
| |
My sleep is moderately disturbed ( 2-3 hours
sleepless). |
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My sleep is greatly disturbed ( 3-5 hours sleepless). |
| |
My sleep is completely disturbed ( 5-7 hours
sleepless). |
|
Section 10- Recreation |
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I am able to engage in all my recreation activities with no
neck pain at all. |
| |
I am able to engage in all my recreation activities, with
some pain in my neck. |
| |
I am able to engage in most, but not all of my usual
recreation activities because of pain in my neck. |
| |
I am able to engage in a few of my usual recreation
activities because of pain in my neck. |
| |
I can hardly do any recreation activities because of pain in
my neck. |
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I can't do any recreation activities at all. |