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NECK, SHOULDER ARM QUESTIONNAIRE by ezm24188

VIEWS: 49 PAGES: 7

									Patient Name: ____________________________________               Date: ___________________


                              NECK, SHOULDER & ARM QUESTIONNAIRE


Age _______ Occupation _________________________ My job involves ______________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Where is your pain and what does it feel like? _____________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

When did this pain begin? Date ____________        ____ Days ____ Weeks ____ Months ____ Years

How did this pain begin? ___ Suddenly ____ Gradually ____ Injury ____ Work
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Do your hands or arms fall asleep, tingle, or go numb yet? ____ Yes ____ No ____ At Night ____ While
working or reaching at or above the shoulders. Explain: ___________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

How long have you had any trouble or aching with your upper back, neck, shoulders, or arms?
_____ weeks _____ mos. _____ years _____ Never had problems before Explain: _________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

How many pillows do you use under your head when sleeping? (Please circle)       0 1 2 3
Type:          Soft           Average               Firm
               Feather        Foam                  Cervical
               Small          Medium                Large

Have you ever had Carpal Tunnel Syndrome? _____ Yes _____ No _____ Don’t Know
Explain: _________________________________________________________________________________
________________________________________________________________________________________

My pain is                                Better       Worse      Unchanged/Don’t Do
   With a cough, sneeze
   or bowel movement                        □             □               □      __________________________
   Sitting at a table or desk with head
   bent forward for long period of time     □             □               □      __________________________
   Turning your head to left                □             □               □      __________________________
   Turning your head to right               □             □               □      __________________________
   Bending your head to left                □             □               □      __________________________
   Bending your head to right               □             □               □      __________________________
   Bending your head forward                □             □               □      __________________________
   Bending back to look up                  □             □               □      __________________________
   Lying flat on stomach                    □             □               □      __________________________
   Lying on back                            □             □               □      __________________________
   Lying on left side                       □             □               □      __________________________
   Lying on right side                      □             □               □      __________________________



Page 1 of 7
Patient Name: ____________________________________               Date: ___________________


My pain is                            Better            Worse     Unchanged/Don’t Do
   Upon waking in morning               □                 □             □      __________________________
   Mid-morning                          □                 □             □      __________________________
   Later in the day                     □                 □             □      __________________________
   Middle of night or when sleeping     □                 □             □      __________________________
   Working with arms up                 □                 □             □      __________________________
   Carrying or lifting                  □                 □             □      __________________________
   Doing housework                      □                 □             □      __________________________
   Weather change (damp, wet, cold)     □                 □             □      __________________________

Have you seen anyone else for this problem? ___ Yes ____ No
If so, please list whom, what they said and did:
     1. _________________________________________________________________________________
________________________________________________________________________________________
     2. _________________________________________________________________________________
________________________________________________________________________________________
     3. _________________________________________________________________________________
________________________________________________________________________________________

This made my problem:
                           Not Used            Better           Worse       Unchanged
Pain Killer                     □                □                □             □
Muscle Relaxant                 □                □                □             □
Nerve Pills                     □                □                □             □
Heating Pad                     □                □                □             □
Ice                             □                □                □             □
Stretches                       □                □                □             □
Exercises                       □                □                □             □
Manipulation                    □                □                □             □
Cervical Collar                 □                □                □             □
Braces/Supports                 □                □                □             □
Massage                         □                □                □             □
Physical Therapy                □                □                □             □
Traction                        □                □                □             □
Cervical Pillow                 □                □                □             □

Additional Comments: _____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

What other treatments, movements or activities not previously mentioned made your discomfort better?
________________________________________________________________________________________
________________________________________________________________________________________

Have any treatments, movements or activities not previously mentioned made your discomfort worse?
________________________________________________________________________________________
________________________________________________________________________________________

How often do you experience headaches? _____ Daily _____ x/Wk. _____ x/Mo. _____ Never
Explain: _________________________________________________________________________________
________________________________________________________________________________________

Have you ever had an x-ray, CT scan, MRI or bone scan of any part of your body?
___ Yes ___ No       What part, by whom, and when? ___________________________________________
________________________________________________________________________________________




Page 2 of 7
Patient Name: ____________________________________              Date: ___________________


Have you ever hit your head, hurt your neck or shoulder, or been in an automobile accident?
_____ Yes _____ No Explain: ______________________________________________________________
_________________________________________________________________________________________

Have you ever had any fractures, dislocations, past sprains, strains, or problems with your neck, shoulders, arms
or hands? _____ Yes _____ No Explain: _____________________________________________________
_________________________________________________________________________________________

What is the most aggravating thing about this problem? ____________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________




Page 3 of 7
Patient Name: ____________________________________               Date: ___________________


                      PHYSICAL THERAPY RELATIVE CONTRAINDICATIONS


The following list consists of conditions which may contraindicate using certain types of therapy we have in our
Physical Therapy/Rehabilitation room. Please read through this list carefully and circle any of the following that
you may have. Also list the year or date that you first had the disorder or procedure/implant and any details that
you can provide. If you do not understand any of the terms or conditions listed below, please ask for help.

Y       N       1.      Tumor
Y       N       2.      Tuberculosis
Y       N       3.      Pregnancy
Y       N       4.      Pacemaker
Y       N       5.      Blood clots or phlebitis
Y       N       6.      Problems with circulation
Y       N       7.      Use of an anticoagulant (blood thinner)
Y       N       8.      Metallic implant or joint replacement
Y       N       9.      Surgical clips, shrapnel or other metal fragments
Y       N       10.     Skin diseases or rashes
Y       N       11.     Hypersensitivity to hot/cold
Y       N       12.     Intrauterine Device or I.U.D.
Y       N       13.     Vasculitis/Raynauds
Y       N       14.     Impaired sensation or loss of feeling
Y       N       15.     Blood or bleeding disorder


Comments: ___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________


I hereby certify that the above statements are true to the best of my knowledge.



_______________________________________                           _________________________
Signature                                                         Date


_______________________________________
Witness




Page 4 of 7
Patient Name: ____________________________________            Date: ___________________


                                          VISUAL ANALOGUE SCALE

Please list area of complaint(s) below:             Please mark on this line with an X the level or intensity of pain
                                                    that you are presently experiencing:

                                                    Absolutely pain free            Worst pain you have ever felt


_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________




Page 5 of 7
Patient Name: ____________________________________                       Date: ___________________


                                                   NECK DISABILITY INDEX

Please Read: This questionnaire is designed to enable us to understand how much your neck pain has affected
your ability to manage your everyday activities. Please answer each Section by circling the ONE CHOICE that
most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE
JUST CIRCLE THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.

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




Page 6 of 7
Patient Name: ____________________________________               Date: ___________________



                                           PAIN DRAWING – FULL BODY


              Mark the areas on your body where you feel the described sensations. Use the appropriate
              letter as noted below. Include all affected areas.


              P = Sharp or Stabbing Pain         B = Burning            T = Tingling or Pins and Needles
              N = Numbness                       S = Stiffness          A = Ache or Dull Pain




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