Location: HealthCARE Express Interventional Pain Management 3515 Richmond Road Texarkana TX, 75503 Phone: (903) 831-5454 Fax: (877) 227-8395

HealthCARE Express Interventional Pain Management

3515 Richmond Road Texarkana, TX 75503

Phone: 903-831-5454 Fax: 1-877-227-8395

Directions:

➢ From I-30: Take the Richmond Road Exit (Exit: 220B)

➢ Turn on Richmond Road, going North

➢ Drive 1 mile down Richmond Road, you will see HealthCARE Express to your left side, immediately before

you reach the Richmond Road / Moores Lane Intersection

➢ The Pain Management Department entrance is on the back side of the HealthCARE Express building.

Please drive around to the back side of the building and come through the back entrance.

Thank you for choosing HealthCARE Express for your medical needs. We look forward to meeting with you soon.

CONSENT FOR TREATMENT: Healthcare Express and their employees evaluate and treat the above patient for medical complaint and illnesses. This includes taking of medical information, evaluation by physical examination, obtaining of bodily fluids for laboratory testing, obtaining of X-rays for diagnosis, the administration of medications for treatment, and any other treatment or evaluation that may be necessary. If, at any time, I do not wish to have these services rendered, I may state so and they will not be provided, but an AMA form may need to be signed by the patient. All of my information will remain confidential. I acknowledge that I have been offered a copy of Healthcare Express Notice of Privacy Practices. ___________initials ASSIGNMENT OF BENEFITS: I authorize the release of any medical information and payment of medical benefits to Healthcare Express for services necessary to process this claim and any future claims. I agree to be responsible for any deductible, co-insurance, co-pay, or any other balance not paid by my insurance. ________initials FINANCIAL POLICY: We are committed to providing you with the best possible medical care; if you have special needs, we are here to work with you. The following information is provided to avoid any misunderstanding or disagreement concerning payment of professional services. PAYMENT IS DUE IN FULL AT THE TIME OF SERVICE: Co-payment will be collected before you are seen. Payment can be made by cash, check or credit card. If you have insurance that we do not participate with, our office will be happy to file the claim upon request; however, payment in full is expected at the time of service. If you have questions about your insurance coverage, we will be happy to assist you. Specific coverage issues should be directed to your insurance company. It is however, understood and agreed that the Responsible Party is responsible for all monies due for services rendered in the event insurance does not pay for these services. ALL CHARGES ARE AN ESTIMATE AND FINALIZED WHEN YOUR INSURANCE COMPANY PROCESSES YOUR CLAIMS. _________initials A 20% DISCOUNT has been applied to the total bill for patients paying self-pay prices at the time of service. This discount does not apply to patients with insurance. _______initials If laboratory tests must be sent to an outside source for further evaluation, the responsible party understands they will be responsible for charges from that facility. _________initials When visiting our facilities After hours, nights and weekends a fee may be applied to the charges billed to your insurance company which is reasonable and customary in our contracts. _____initials

NOTE: It is company policy to run your check by EFT or your credit card. For private pays (no insurance) all charges for the visit is due before you are seen. Please note that you may have a balance at the end of your visit, which must be paid before you exit the clinic By signing below, I agree that I have read and understand the terms of this agreement.

______________________________________________________________________________________________________________________ PATIENT SIGNATURE DATE

PATIENT INFORMATION

SSN: HOME PHONE:

FIRST NAME: CELL PHONE:

LAST NAME: EMAIL ADDRESS:

MIDDLE NAME: HOW DID YOU HEAR ABOUT US?

DATE OF BIRTH: MARITAL STATUS:

SEX: M OR F EMPLOYER:

ADDRESS: EMPLOYER PHONE NUMBER:

CITY: RACE: HISPANIC/LATINO Y OR N

STATE: ZIP CODE: PREFERRED LANGUAGE:

EMERGENCY CONTACT:

NAME: RELATIONSHIP: PHONE NUMBER:

PERSONAL INSURANCE COVERAGE

Primary Insurance: Secondary Insurance:

NAME OF POLICY HOLDER: NAME OF POLICY HOLDER:

MEMBER ID NUMBER: MEMBER ID NUMBER:

GROUP NUMBER: GROUP NUMBER:

POLICY HOLDERS SSN: DOB: POLICY HOLDERS SSN: DOB:

RELATIONSHIP TO PATIENT: RELATIONSHIP TO PATIENT:

GUARANTOR’S INFORMATION (If patient is under the age of 18):

FIRST NAME: LAST NAME: DOB: SSN:

ADDRESS: CITY: STATE: ZIP CODE:

Prescription History Consent

I voluntarily consent to provide HealthCare Express access to, and use of my,

prescription medication history from other healthcare providers or third party pharmacy

benefit payors for treatment purposes. I understand that my prescription history (which

includes but is not limited to prescriptions, labs, and other and all health care drug historical

information) from multiple other unaffiliated medical providers, insurance companies, and

pharmacy benefit managers may be viewable by my providers and staff at HealthCare

Express, and it may include prescriptions dating back for several years.

I expressly acknowledge that HealthCare Express may use health information exchange

systems to electronically transmit, receive and/or access my prescription history.

I understand that this Prescription History Consent will be valid and remain in effect as

long as I attend and/or receive services from HealthCare Express, unless specifically

revoked by me in writing with such written notice provided to each practice site I attend or

from which I receive services.

I certify that I have read this form or it has been read to me.

Date: ______________________

Print Name (Patient): _______________________________________________________

DOB: _____________________

Signature of Patient/Legally Authorized Representative: ___________________________

Relationship to Patient (if Patient not signing): ___________________________________

For patients requiring translation or verbal reading of this document, the person reading or

translating should document and sign below:

Reader/Translator Signature: _________________________ Date: ___________________

AUTHORIZATION FOR

RELEASE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Your privacy is important to Healthcare Express. As a result, we ask you to complete the following authorization related to your personal health and health-related benefits.

I hereby authorize use and disclosure of protected health information (PHI), as described below.

This Authorization relates only to the PHI of: NAME: ______________________________________ Last four digits of Social Security Number: ____________

I hereby authorize Healthcare Express to release information about my account at Healthcare Express to the following people: ___________________________________________________ __________________________________________ Name Relationship to Patient ____________________________________________________ __________________________________________ Name Relationship to Patient ____________________________________________________ __________________________________________ Name Relationship to Patient I hereby authorize Healthcare Express to release information about my medical treatment (PHI) to the following people: ____________________________________________________ __________________________________________ Name Relationship to Patient ____________________________________________________ __________________________________________ Name Relationship to Patient ____________________________________________________ __________________________________________ Name Relationship to Patient

I have read and understand the following statements about my rights:

A.) I may revoke this authorization at any time by giving written notice to Healthcare Express. I understand that my revocation will not affect any use or disclosure of my PHI that was made in reliance on the authorization before I revoked it.

B) My health provider cannot require me to sign this authorization in order to be eligible for services or treatment.

C) It is possible that the persons who receive information based on this authorization may disclose it to others and as a result the information may no longer be protected by federal privacy rules.

D) This Authorization for my personal health information does not apply to the release of the same information for any spouse or child that I may cover on my medical benefits or account at Healthcare Express. I understand that my spouse or child over 18 must provide independent Authorization for release of their personal PHI.

I acknowledge that I have received and signed a copy of this authorization.

_______________________________________________________ _________________________

Patient or legally authorized individual signature Date

AUTHORIZATION TO LEAVE

PERSONAL HEALTH INFORMATION

BY ALTERNATE MEANS

Patient Name: ___________________________________________ Date of Birth: _______________

Patient Mailing Address: _____________________________________________________________

Preferred Pharmacy if necessary: ______________________________________________________

May leave detailed message on telephone answering machine at home # (____) __________________

May leave detailed message on voicemail at work # (______) __________________________________

May leave information with Spouse (name): ________________________________________________

May leave information with other family member (name): _____________________________________

May leave detailed message on cellular phone # _____________________________________________

May leave detailed message at a different location # _________________________________________

May send detailed message by email to: ___________________________________________________

With my signature below, I acknowledge and understand that this information will be kept in my medical record and the above parameters will be abided by until revoked by me in writing. It is my responsibility to notify HealthCARE Express should I change one or more of the telephone numbers listed above OR any one of the contact names.

_______________________________________________________ _________________________

Patient or legally authorized individual signature Date

Patient name: ___________________________ Date of Birth: ________________

Office use only: BP: ______ /______ HR: _______ Resp: _______ 02: _______ Height: _________ Weight: __________

Current and Past Medical History

Name: __________________________________________________ DOB: _____________________ Date: ___________________________

Who Referred you? __________________________________________________________________________________________________

Reason for visit: ______________________________________________________________________________________________________

DRUG ALLERGIES: ☐None CURRENT MEDICATIONS: ☐None ☐See Attached

NAME DOSE HOW OFTEN PHYSICIAN

OTHER ALLERGIES: ☐None

☐Latex ☐Contrast

☐Iodine ☐Lidocaine

☐Adhesive

HISTORY OF PAIN SYMPTOMS:

Where do you have pain? ________________________________________________________________________________________________________________________________________________

What does your pain feel like? ☐ Sharp ☐ Stabbing ☐ Dull ☐ Shooting ☐ Cramping ☐ Aching ☐ Burning ☐ Throbbing ☐ Numb/Tingling ☐ Devastating ☐ Pressure ☐ Pulsing ☐ Lightning ☐ Crawling ☐ Other_________________________________________

When did your pain begin? ________________________________________________________________________________________________________________________________________________

Was there a specific cause? ________________________________________________________________________________________________________________________________________________

Is there a certain time of day that your pain is worse? ☐ AM ☐ PM ☐ Other ___________________________________________________

What makes your pain worse? ☐ Sitting ☐ Standing ☐ Walking ☐ Bending ☐ Twisting ☐ Lying down ☐ Coughing ☐ Other_______________________________________________________________________________________________________________________________________

What makes your pain better? ☐ Sitting ☐ Standing ☐ Lying down ☐ Rest ☐ Medication ☐ Changing positions ☐ Other_______________________________________________________________________________________________________________________________________

Do you have any of the following? ☐ Numbness ☐ Tingling ☐ Weakness ☐ Bowel Incontinence ☐ Bladder Incontinence

What have you done to treat your pain? _______________________________________________________________________________________________ Physical Therapy Chiropractic Care Massage Therapy Acupuncture TENS Unit

Have you had back or neck injections before?

Have you had back or neck surgery before?

Have your symptoms been getting worse?

☐ No ☐ Yes ☐ When ________________________________________ Did it help? ☐ No ☐ Yes ☐ Made me worse ☐ No ☐ Yes ☐ When ________________________________________ Did it help? ☐ No ☐ Yes ☐ Made me worse ☐ No ☐ Yes ☐ When ________________________________________ Did it help? ☐ No ☐ Yes ☐ Made me worse ☐ No ☐ Yes ☐ When ________________________________________ Did it help? ☐ No ☐ Yes ☐ Made me worse ☐ No ☐ Yes ☐ When ________________________________________ Did it help? ☐ No ☐ Yes ☐ Made me worse

☐ No ☐ Yes If so, what/when? ________________________________________________

☐ No ☐ Yes If so, what/when? ________________________________________________

☐ No ☐ Yes

Patient name: ___________________________ Date of Birth: ________________

Office use only: BP: ______ /______ HR: _______ Resp: _______ 02: _______ Height: _________ Weight: __________

PLEASE INDICATE IF YOU HAVE HAD THE FOLLOWING PAST MEDICAL HISTORY OR SURGERIES:

Cardiac: Endocrine: Mental Health: Gastrointestinal: Musculoskeletal: ☐ Coronary Artery Disease ☐ Diabetes I ☐ Depression ☐ GERD/ Ulcers ☐ Fibromyalgia ☐ High Blood Pressure ☐ Diabetes II ☐ Anxiety ☐ Crohn’s Disease ☐ Chronic Fatigue ☐ High Cholesterol ☐ Hypothyroidism ☐ Bipolar Disorder ☐ Irritable Bowel Disease ☐ Osteoarthritis ☐ Heart Attacks ☐ Hyperthyroidism ☐ Schizophrenia ☐ Gallbladder Disease ☐ Rheumatoid Arthritis ☐ Arrhythmia / Pacemaker ☐ Adrenal Insufficiency ☐ ADHD ☐ Hepatitis A/B/C ☐ Lupus ☐ Bypass Surgery ☐ Menopause ☐ Suicide Attempts ☐ Pancreatitis ☐ Raynaud’s Disease Neurological: Pulmonary: ENT: Renal: Hematological: ☐ MS ☐ Asthma ☐ Seasonal Allergies ☐ Kidney Failure ☐ Bleeding ☐ Stroke ☐ COPD ☐ Sinus Infection ☐ Kidney Stones ☐ Anemia ☐ Migraine HA ☐ Sleep Apnea ☐ Ear Infection ☐ Incontinence ☐ Leukemia ☐ Tension HA ☐ Bronchitis ☐ Dental Problems ☐ Urinary Tract Infection ☐ Hypercoaguable Disorder ☐ Seizures ☐ Pneumonia ☐ Other Problems: ☐ Polio/Guillain-Barre ☐ Emphysema

Prior Surgeries: ________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Have you had Cancer? ☐ No ☐ Yes If yes, type/course:

_______________________________________________

_______________________________________________________________________

FAMILY HISTORY:

☐ Hypertension ☐ Stroke ☐ Fibromyalgia ☐ Depression ☐ Asthma ☐ Cancer. If yes, type/course

☐ High Cholesterol ☐ Migraine HA ☐ Rheumatoid Arthritis ☐ Anxiety ☐ COPD

☐ Heart Attacks ☐ Diabetes ☐ Lupus ☐ Bipolar Disorder ☐ Bleeding

SOCIAL HISTORY:

Do you currently use or have you ever used any of the following? ☐ THC ☐ Crack ☐ Cocaine ☐ Methamphetamine ☐ Heroin ☐ Ecstasy ☐ PCP ☐ Other _________________________________________ If yes, please explain: _________________________________________________________________________________________________________________________

Do you smoke?

Do you drink alcohol? Do you work?

PLEASE INDICATE IF YOU HAVE USED OR TRIED THE FOLLOWING PAIN MEDICATIONS: ☐ Oxycodone ☐ Fentanyl ☐ Tapentelol (Nucynta) ☐ Tizanidine ☐ Gabapentin ☐ Cymbalta ☐ Oxycontin ☐ Morphine IR/ER ☐ Buprenorphine (Butrans) ☐ Methocarbamol (Robaxin) ☐ Lyrica ☐ Ibuprofen ☐ Percocet ☐ Hydromorphone (Dilaudid) ☐ Levorphanol ☐ Cyclobenzaprine (Flexeril) ☐ Amitriptyline ☐ Diclofenac ☐ Hydrocodone ☐ Exalgo (Dilaudid) ☐ Methadone ☐ Baclofen ☐ Nortriptyline ☐ Naproxen ☐ Tramadol ☐ Oxymorphone (Opana) ☐ Subxone ☐ Carisoprodol (Soma) ☐ Effexor ☐ Tylenol

On the drawing to the left, please indicate where you are having pain by using the symbols below to describe your symptoms: ×× Sharp/stabbing +++ Aching/Dull === Burning ⁄ ⁄ ⁄ Numb or Tingling

What is today’s pain?

Average pain this week:

Worst pain this week:

% relief from medications:

Pain Medications Effective:

Right Left Left Right

☐ Yes ☐ No ☐ Quit ☐ When? _______________________________________________________________

☐ Yes ☐ No ☐ Quit ☐ When? _______________________________________________________________

☐ Yes ☐ No ☐ Retired ☐ Disabled

_______ /10

_______ /10

_______ /10

_______%

☐ Yes ☐ No

Patient name: ___________________________ Date of Birth: ________________

Office use only: BP: ______ /______ HR: _______ Resp: _______ 02: _______ Height: _________ Weight: __________

PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING SYMPTOMS TODAY: Constitutional: Cardiac: Mental Health: Hematologic: Integument: ☐ Fevers ☐ Chest Pain ☐ Depression ☐ Taking Blood Thinners ☐ Rash ☐ Chills ☐ Palpitations ☐ Anxiety ☐ Easy Bruising ☐ Hives ☐ Night Sweats ☐ Fast Heart Rate ☐ Suicidal Thoughts ☐ Excessive Bleeding ☐ Other ☐ Slow Heart Rate ☐ Slow Heart Rate ☐ Homicidal Thoughts ☐ Swollen Glands Endocrine: ☐ Edema (Swelling) ☐ Edema (Swelling) ☐ Sleep Difficulty ☐ Other ☐ Hair Loss ☐ Weight Gain/Loss ☐ Other ☐ Restlessness Musculoskeletal: ☐ Excessive Thirst ☐ Other Neurological: ☐ Crying ☐ Neck Pain ☐ Other ENT: ☐ Numbness/Tingling ☐ Agitation ☐ Low Back Pain Gastrointestinal ☐ Hearing Difficulty ☐ Seizures ☐ Insomnia ☐ Muscle Pain ☐ Diarrhea ☐ Visual Changes ☐ Memory Impairment ☐ Other ☐ Muscle Weakness ☐ Constipation ☐ Swallowing Difficulty ☐ Weakness Pulmonary: ☐ Morning Stiffness ☐ Nausea / Vomiting ☐ Dental Problems ☐ Incontinence ☐ Cough ☐ Joint Pain ☐ Abdominal Pain ☐ Hoarseness ☐ Loss of Balance ☐ Wheezing ☐ Joint Stiffness ☐ Jaundice ☐ Headache ☐ Loss of Coordination ☐ Shortness of Breath ☐ Difficulty walking ☐ Reflux ☐ Other ☐ Other ☐ Other ☐ Other ☐ Other

ARE YOU PREGNANT OR IS THERE A CHANCE THAT YOU MAY BE PREGNANT? ☐ Yes ☐ No ☐ N/A

Patient Signature: _________________________________________________________ Date: _________________________________

©2009 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No other uses or alterations are authorized or permitted by copyright holder. Permissions questions: PainEDU@inflexxion.com. The SOAPP®-R was developed with a grant from the National Institutes of Health and an educational grant from Endo Pharmaceuticals.

SOAPP®-R The following are some questions given to patients who are on or being considered for medication for their pain. Please answer each question as honestly as possible. There are no right or wrong answers.

Nev

er

Se

ldo

m

So

me

tim

es

Oft

en

Ve

ry O

fte

n

0 1 2 3 4 1. How often do you have mood swings?

2. How often have you felt a need for higher doses of medication to treat your pain?

3. How often have you felt impatient with your doctors?

4. How often have you felt that things are just too overwhelming that you can't handle them?

5. How often is there tension in the home?

6. How often have you counted pain pills to see how many are remaining?

7. How often have you been concerned that people will judge you for taking pain medication?

8. How often do you feel bored?

9. How often have you taken more pain medication than you were supposed to?

10. How often have you worried about being left alone?

11. How often have you felt a craving for medication?

12. How often have others expressed concern over your use of medication?

©2009 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No other uses or alterations are authorized or permitted by copyright holder. Permissions questions: PainEDU@inflexxion.com. The SOAPP®-R was developed with a grant from the National Institutes of Health and an educational grant from Endo Pharmaceuticals.

Nev

er

Se

ldo

m

So

me

tim

es

Oft

en

Ve

ryO

fte

n

0 1 2 3 413. How often have any of your close friends had a

problem with alcohol or drugs?

14. How often have others told you that you had a bad temper?

15. How often have you felt consumed by the need to get pain medication?

16. How often have you run out of pain medication early?

17. How often have others kept you from getting what you deserve?

18. How often, in your lifetime, have you had legal problems or been arrested?

19. How often have you attended an AA or NA meeting?

20. How often have you been in an argument that was so out of control that someone got hurt?

21. How often have you been sexually abused?

22. How often have others suggested that you have a drug or alcohol problem?

23. How often have you had to borrow pain medications from your family or friends?

24. How often have you been treated for an alcohol or drug problem?

Please include any additional information you wish about the above answers. Thank you.

The Revised Oswestry Disability Index (for low back pain/dysfunction)

Patient name: Date of Birth: Date: ________________

This questionnaire has been designed to give your therapist information as to how your back pain has affected your ability to

manage everyday life. Please answer every section and mark in each section only the ONE box that applies to you. We realize that you

may consider that two of the statements in any one section relate to you, but please just mark the box that most closely describes your

problem.

SECTION 1 – PAIN INTENSITY

The pain comes and goes and is very mild.

The pain is mild and does not vary much.

The pain comes and goes and is moderate.

The pain is moderate and does not vary much.

The pain come and goes and is very severe

SECTION 2 – PERSONAL CARE

I would not have to change my way of washing or dressing in

order to avoid pain

I do not normally change my way of washing or dressing even

though it causes some pain.

Washing and dressing increases the pain but I manage not to

change my way of doing it.

Washing and dressing increases the pain and I find it

necessary to change my way of doing it.

Because of my pain, I am unable to do some washing and

dressing without help.

Because of the pain, I am unable to do any washing and

dressing without help.

SECTION 3 – LIFTING

I can lift heavy weights without extra pain.

I can lift heavy weights, but it causes extra pain.

Pain prevents me from lifting heavy weights off the floor,

but I mange if it is conveniently positioned (e.g., on a table).

Pain prevents me from lifting heavy weights off the floor.

Pain prevents me from lifting heavy weights, but I can

manage light to medium weights if they are conveniently

positioned.

I can only lift very light weights at the most.

SECTION 4 – WALKING

I have no pain on walking.

I have some pain on walking, but it does not increase with

distance.

I cannot walk more than one mile without increasing pain.

I cannot walk more than ½ mile without increasing pain.

I cannot walk more than ¼ mile without increasing pain.

I cannot walk at all without increasing pain.

SECTION 5 – SITTING

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 only hour.

Pain prevents me from sitting more than ½ hour.

Pain prevents me from sitting more than 10 minutes.

I avoid sitting because it increases pain right away.

SECTION 6 – STANDING

I can stand as long as I want without pain.

I have some pain on standing, but it does not increase with time.

I cannot stand for longer than 1 hour without increasing pain.

I cannot stand for longer than ½ hour without increasing pain.

I cannot stand for longer than 10 minutes without increasing pain.

I avoid standing because is increases the pain right away.

SECTION 7 – SLEEPING

I get no pain in bed.

I get pain in bed, but it does not prevent me from sleeping well.

Due to pain, my normal night’s sleep is reduced by less than 1/4.

Due to pain, my normal night’s sleep is reduced by less than 1/2.

Due to pain, my normal night’s sleep is reduced by less than 3/4.

Pain prevents me from sleeping at all.

SECTION 8 – SOCIAL LIFE

My social life is normal and gives me no pain.

My social life is normal, but increases the degree of pain.

Pain has no significant effect of me social life apart from limiting

my more energetic interests (e.g., dancing, etc.)

Pain has restricted my social life and I do not go our very often.

Pain has restricted my social life to my home.

I have hardly any social life because of the pain.

SECTION 9 – TRAVELING

I get no pain while traveling.

I get some pain while traveling, but none of my usual forms of

travel makes it any worse.

I get extra pain while traveling, but it does not compel me to seek

alternative forms of travel.

I get extra pain while traveling, which compels me to seek

alternative forms of travel.

Pain restricts all forms of travel.

Pain prevents all forms of travel except that done lying down.

SECTION 10 – CHANGING DEGREE OF PAIN

My pain is rapidly getting better.

My pain fluctuates, but is definitively getting better.

My pain seems to be getting better, but improvement is slow at

present.

My pain is neither getting better nor worse.

My pain is gradually worsening.

My pain is rapidly worsening.

Oswestry Disability Index for Neck Pain

Patient name: Date of Birth: Date: _________________

This questionnaire has been designed to give your doctor information as to how your neck pain has affected your ability to manage in everyday life. Please answer every question by placing a mark in the one box that best describes your condition today. We realize you may feel that two of the statements may describe your condition, but please mark only the box which most closely describes your current condition.

PAIN INTENSITY:

0 I have no pain at the moment.

1 The pain is very mild at the moment.

2 The pain is moderate at the moment.

3 The pain is fairly severe at the moment.

4 The pain is very severe at the moment.

5 The pain is the worst imaginable at the moment.

PERSONAL CARE (WASHING, DRESSING, ETC.):

0 I can look after myself normally without causing extra pain.

1 I can look after myself normally, but it causes a little extra pain.

2 It is painful to look after myself, and I am slow and careful.

3 I need some help, but manage most of my personal care.

4 I need help every day in most aspects of my care.

5 I do not get dressed, wash with difficulty and stay in bed.

LIFTING:

0 I can lift heavy weights without increased pain.

1 I can lift heavy weights, but it causes increased pain.

2 Pain prevents me from lifting heavy weights off the floor, but I can

manage if the weights are conveniently positioned (ex. on a table).

3 Pain prevents me from lifting heavy weights, but I can manage

light to medium weights if they are conveniently positioned.

4 I can lift only very light weights.

5 I cannot lift or carry anything at all.

READIING:

0 I can read as much as I want to with no pain in my neck.

1 I can read as much as I want to with slight pain in my neck.

2 I can read as much as I want to with moderate pain in my neck.

3 I cannot read as much as I want because of moderate pain in my

neck.

4 I cannot read as much as I want because of severe pain in my

neck.

5 I cannot read at all.

HEADACHES:

0 I have no headaches at all.

1 I have slight headaches which come infrequently.

2 I have moderate headaches which come infrequently.

3 I have moderate headaches which come frequently.

4 I have severe headaches which come frequently.

5 I have headaches almost all the time.

CONCENTRATION:

0 I can concentrate fully when I want to with no difficulty.

1 I can concentrate fully when I want to with slight difficulty.

2 I have a fair degree of difficulty in concentrating when I want to.

3 I have a lot of difficulty in concentrating when I want to.

4 I have a great deal of difficulty in concentrating when I want to.

5 I cannot concentrate at all.

SLEEPING:

0 I have no trouble sleeping.

1 My sleep is slightly disturbed (less than 1 hour sleepless).

2 My sleep is mildly disturbed (1-2 hours sleepless).

3 My sleep is moderately disturbed (2-3 hours sleepless).

4 My sleep is greatly disturbed (3-5 hours sleepless).

5 My sleep is greatly disturbed (5-7 hours sleepless).

WORK:

0 I can do as much work as I want to.

1 I can only do my usual work, but no more.

2 I can do most of my usual work, but no more.

3 I cannot do my usual work.

4 I can hardly do any work at all.

5 I cannot do any work at all.

DRIVING:

0 I can drive my car without any neck pain.

1 I can drive as long as I want with slight pain in my neck.

2 I can drive as long as I want with moderate pain in my neck.

3 I cannot drive as long as I want because of moderate pain in my neck.

4 I can hardly drive at all because of severe pain in my neck.

5 I cannot drive my car at all.

RECREATION:

0 I am able to engage in all of my recreational activities with no neck pain.

1 I am able to engage in all of my recreational activities with some pain in

my neck.

2 I am able to engage in most, but not all of my recreational activities

because of pain in my neck.

3 I am able to engage in a few of my recreational activities because of pain

in my neck.

4 I can hardly do any recreational activities because of pain in my neck.

5 I cannot do any recreational activities at all.

Patient’s Score:

__________________ X 100 = ________ % Disability # Sections Completed x 5