Use the mouse and click on the option that represents closest to how you feel today
You have not indicated your choice here I have no pain at present 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
You have not indicated your choice here I can look after myself normally without causing 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 do not get dressed. I wash with difficulty and stay in bed
You have not indicated your choice here I can lift heavy objects without extra pain I can lift heavy objects but it gives extra pain I can't lift heavy objects from off the floor but off a table is OK I can't lift heavy objects but light to medium ones are OK I can only lift very light weights I cannot lift of carry anything at all
You have not indicated your choice here 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 pain in my neck I can't read as much as I want to because of moderate pain in my neck I can hardly read at all because of pain in my neck I cannot read at all
You have not indicated your choice here 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 the time
You have not indicated your choice here 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 in concentrating 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 I cannot concentrate at all
You have not indicated your choice here yet 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 any work at all
You have not indicated your choice here 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 neck pain I can hardly drive at all because of severe pain in my neck I can't drive my car at all
You have not indicated your choice here I have no trouble sleeping My sleep is slightly disturbed (less than 1hr sleepless) My sleep is mildly disturbed (1-2hrs sleepless) My sleep is moderately disturbed (2-3hrs sleepless) My sleep is greatly disturbed (3-5hrs sleepless) My sleep is completely disturbed (5-7hrs sleepless)
You have not indicated your choice here I can do all my recreation activities without neck pain I can do all my recreation activities with some neck pain I can do most recreation activities because of neck pain I can do only a few of my usual activities because of neck pain I can hardly do any recreation activities because of neck pain I can't do any recreation activities at all
You can review your responses by clicking the forward and back links. Your selections remain until you click the < Submit > button below. Date: Date of neck-related problem beginning (approx if not sure): First name: Last name: Male Female
