Progress Evaluation Form

Progress Evaluation

In the current rating fields, please rate the pain that you are currently experiencing on a scale of 0-10, 10 being the worst pain and 0 being none. Under frequency and improvement, please check all boxes that apply.

Constantly
Daily
Several Times a Week
Several Times a Month
Never
Constantly
Daily
Several Times a Week
Several Times a Month
Never
Constantly
Daily
Several Times a Week
Several Times a Month
Never
Constantly
Daily
Several Times a Week
Several Times a Month
Never
Constantly
Daily
Several Times a Week
Several Times a Month
Never
Constantly
Daily
Several Times a Week
Several Times a Month
Never
Constantly
Daily
Several Times a Week
Several Times a Month
Never
Bending
Concentrating
Doing computer work
Gardening
Playing Sports
Recreation Activities
Shoveling
Sleeping
Watching TV
Carrying
Dancing
Dressing
Lifting
Pushing
Rolling Over
Sitting
Standing
Working
Climbing
Doing chores
Driving
Performing Sexual Activity
Reading
Running
Sitting to Standing
Walking
No Improvement
Some Improvement
Considerable Improvement
100% Improvement
Poor
Fair
Good
Excellent
To get out of pain
To get healthy and stay healthy for the rest of your life
Other
All of the above

Low Back Disability Index

This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to mange in everyday life. Please answer every section and mark in each section only one box that applies to you. 

I can tolerate the pain without having to use painkillers
The pain is bad but I can manage without taking painkillers
Painkillers give complete relief from pain
Painkillers give moderate relief from pain
Painkillers give very little relief from pain
Painkillers have no effect on the pain and I do not use them
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
I can lift heavy weights without extra pain
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, but I can manage light to medium weights if they are conveniently positioned
I can lift very light weights
I cannot lift of carry anything at all
Pain does not prevent me from walking any distance
Pain prevents me from walking more than one mile
Pain prevents me from walking more than one-half mile
Pain prevents me from walking more than one-quarter mile
I can only walk using a stick of crutch
I am in bed most of the time and have to crawl to the toilet
I can sit in any chair as long as I like
I can only sit in my favorite chair as long as I like
Pain prevents me from sitting more than one hour
Pain prevents me from sitting more than 30 minutes
Pain prevents me from sitting more than 10 minutes
Pain prevents me from sitting almost all of the time
I can stand as long as I want without extra pain
I can stand as long as I want but it gives extra pain
Pain prevents me from standing more then 1 hour
Pain prevents me from standing more then 30 minutes
Pain prevents me from standing more than 10 minutes
Pain prevents me from standing at all
Pain does not prevent me from sleeping well
I can sleep well only by using tablets
Even when I take tablets I have less than 6 hours sleep
Even when I take tablets I have less than 4 hours sleep
Even when I take tablets I have less than 2 hours sleep
Pain prevents me from sleeping at all
My social life is normal and gives me no extra pain
My social life is normal but increases the degree of pain
Pain has no significant effect on my social life apart from limiting my more energetic interests
Pain has restricted my social life and I do not go out as often
Pain has restricted my social life to my home
I have no social life because of pain
I can travel anywhere without extra pain
I can travel anywhere but it gives me extra pain
Pain is bad but I manage journeys less than 1 hour
Pain restricts me to short necessary journeys under 30 minutes
Pain prevents me from traveling except to the doctor or hospital
Pain is bad but I manage journeys over 2 hours
My pain is rapidly getting better
My pain fluctuates but overall is definitely getting better
My pain seems to be getting better but improvement is slow at the present
My pain is neither getting better or worse
My pain is gradually worsening
My pain is rapidly worsening

Neck Disability Index

This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to mange in everyday life. Please answer every section and mark in each section only one box that applies to you.

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
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
I can lift heavy weights without extra pain
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, but I can manage light to medium weights if they are conveniently positioned
I can lift very light weights
I cannot lift or carry anything at all
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 with moderate pain
I cant read as much as I want because of moderate pain in my neck
I can hardly read at all because of severe pain in my neck
I cannot read at all
I have no headaches at all
I have slight headaches which come infrequently
I have slight headaches which come frequently
I have moderate headaches which come infrequently
I have severe headaches which come frequently
I have headaches almost all the time
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
I can do as much work as I want
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
I drive my car without any neck pain
I can drive my car as long as I want with slight pain in my neck
I can drive my car as long as I want with moderate pain in my neck
I can't drive my car as long as I want because of moderate pain in my neck
I can hardly drive my car at all because of severe pain in my neck
I can't drive my car at all
I have no trouble sleeping
My sleep is slightly disturbed
My sleep is moderately disturbed (1-2 hrs sleepless)
My sleep is moderately disturbed (2-3 hrs sleepless)
My sleep is greatly disturbed
My sleep is completely disturbed
I am able to engage in all my recreation activities with no neck pain at all
I am able to engage in all of 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
I can't do any recreation activities at all

Thank you for taking the time to fill out this form.

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950 Yale Ave, Suite 29. Wallingford, CT 06492

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3:00 pm-6:00 pm

Tuesday:

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Wednesday:

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3:00 pm-6:00 pm

Thursday:

8:15 am-10:45 am

Friday:

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Saturday:

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Sunday:

Closed