8 -Driving. 9 -Sleeping

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1 NECK PAIN DISABILITY INDEX QUESTIONNAIRE PLEASE READ: This questinnaire is designed t enable us t understand hw much yur neck pain has affected yur ability t manage yur everyday activities. Please answer each sectin by circling the ONE CHOICE that mst applies t yu. We realize that yu may feel that mre than ne statement may relate t yu, but PLEASE JUST CIRCLE THE ONE. CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. SECTION1-PainIntensity SECTION6-Cncentratin A I have n pain at the mment. B The pain is very mild at the mment. e The pain is mderate at the mment. The pain is fairly severe at the mment. E The pain is very severe at the mment. F The pain is the wrst ima2inable at the mment. SECTION 2.Persnal Care (Washing, Dressing, etc.) A I can lk after myself nrmally withut causing extra pain. B I can lk after myself nrmally, but it causes extra pain. e It is painful t lk after myself and I am slw and careful. I need sme help, but manage mst f my persnal care. E I need help every day in mst aspects f self care. F I d nt get dressed, I wash with difficulty and stay in bed. A I can cncentrate fully when I want t with n difficulty. B I can cncentrate fully when I want t with slight difficulty. e I have a fair degree f difficulty in cncentrating when I want t. D I have a lt f difficulty in cncentrating when I want t. E I have a great deal f difficulty in cncentrating when I want t. F I cannt cncentrate at all. SECTION 7 - Wrk A I can d as much wrk as I want t. B I can nly d my usual wrk, but n mre. e I can d mst f my usual wrk, but n mre. D I cannt d my usual wrk. E I can hardly d any wrk at all. F I cannt d any wrk at all. SECTION 3 - Lifting SECTION 8 -Driving A I can lift heavy weights withut extra pain. B I can lift heavy weights, but it gives extra pain. e Pain prevents me frm lifting heavy weights ff the flr, but I can manage if they are cnveniently psitined, fr example, n a table. Pain prevents me frm lifting heavy weights, but I can manage light t medium weights ifthey are cnveniently psitined. E I can lift very light weights. F I cannt lift r carry anythin2 at all. SECTION 4 - Reading A I can read as much as I want t with n pain in my B I can read as much as I want t with slight pain in my e I can read as much as I want t with mderate pain in my I cannt read as much as I want because f mderate pain in my E I cannt read as much as I want because f severe pain in my F I cannt read at all. SECTION 5 - Headaches A I have n headaches at all. B I have slight headaches which cme infrequently. e I have mderate 6eadaches which cme infrequently. I have mderate headaches which cme frequently. E I have severe headaches which cme frequently. F I have headaches almst all the time. COMMENTS: A I can drive my car withut any neck pain. B I can drive my car as lng as I want with slight pain in my e I can drive my car as lng as I want with mderate pain in my I cannt drive my car as lng as I want because f mderate pain in my E I can hardly drive at all because f severe pain in my F I cannt drive my car at all. SECTION 9 -Sleeping A I have n truble sleeping. B My sleep is slightly disturbed (less than 1 hur sleepless). e My sleep is mildly disturbed (1-2 hurs sleepless). My sleep is mderately disturbed (2-3 hurs sleepless). E My sleep is greatly disturbed (3-5 hurs sleepless). F My sleep is cmpletely disturbed (5-7 hurs) SECTION 10- Recreatin A I am able t engage in all f my recreatinal activities with n neck pain at all. B I am able t engage in all f my recreatinal activities with sme pain in my e I am able t engage in mst, but nt all f my recreatinal activities because f pain in my I am able t engage in a few f my recreatinal activities because f pain in my E I can hardly d any recreatinal activities because f pain in my F I cannt d anv recreatinal activities at all. NAME: DATE: SCORE:

2 Oswestry Lw Back Pain Scale Please rate the severity f yur pain by circling a number belw: N pain Unbearable pain Name Instructins: Please circlethe ONE NUMBERin each sectin which mst clsely describes yurprblem. Sectin 1-Pain Intensity O.The pain cmes and ges and is very mild. 1. The pain is mild and des nt vary much. 2. The pain cmes and ges and is mderate. 3. The pain is mderate and des nt vary much. 4. The pain cmes and ges and is severe. 5. The pain is severe and des nt vary much. Sectin 2 - Persnal Care (Washing, Dressing, etc.) O. I wuld nt have t change my way f washing r dressing in rder t avid pain. 1. I d nt nrmally change my way f washing r dressing even thugh it causes sme pain. 2. Washing and dressing inaease the pain but I manage nt t change my way f ding it 3. Washing and dressing inaease the pain and I find it necessary t change my way f ding it 4. Because f the pain I am unable t d sme washing and dressing withut help. 5. Because f the pain I am unable t d any washing and dressing withut help. Sectin 3- Ufting O. I can liftheavy weights withut extra pain. 1. I can liftheavy weights but it gives extra pain. 2. Pain prevents me liftingheavy weights ff the flr. 3. Pain prevents me liftingheavy weights ff the flr, but I can manage ifthey are cnvenienuy psitined, e.g., n a lable. 4. Pain prevents me liftingheavy weights but I can manage light t medium weights if they are cnvenienuy psitined. 5. I can nly liftvery light weights at mst Sectin 4 - Walking O. I have n pain n walking. 1. I have sme pain n walking but it des nt increase with distance.. 2. I cannt walk mre than 1 mile withut increasing pain. 3. I cannt walk mre than % mile withut increasing pain. 4. I cannt walk mre than % mile withut increasing pain. 5. J cannt walk at all withut increasing pain. Sectin 5-Sitting O.I can sit in any chair as lng as I flke. 1. I can sit nly in my favrite chair as lng as I like. 2. Pain prevents me frm sitting mre than 1 hur. 3. Pain prevents me frm sitting mre than Yzhur. 4. Pain prevents me frm sitting mre than 10 minutes. 5. I avid sitting because it increases pain immediately. Sectin 6- Standing O. I can sland as lng as I want withut pain. 1. I have sme pain n standing but it des nt increase with time. 2. I cannt stand fr lnger than 1 hur withut inaeasing pain. 3. I cannt stand fr lnger than % hur withut increasing pain. 4. I cannt stand fr lnger than 10 minutes withut increasing pain. 5. I avid standing because it inaeases the pain immediately. Sectin 7-Sleeping O. I get n pain in bed. 1. I get pain in bed but it des nt prevent me frm sleeping well. 2. Because f pain my nnnai nights sleep is reduced by less than ne-quarter. 3. Because f pain my nnnal nights sleep is reduced by less than ne-half. 4. Because f pain my nrmal nights sleep is reduced by less than three-quarters. 5. Pain prevents me frm sleeping at all. Sectin 8- Scial Ute O.My scial life is nrmal and gives me n pain. 1. My scial life is nrmal but it inaeases the degree f pain. 2. Pain has n significant effect n my scia1life apart frm limiting my mre energetic interests, e.g., dancing, ete. 3. Pain has restricted my scial life and I d nt g ut very ften. 4. Pain has restricted my scial life t my hme. 5. I have hardly any scial fife because f the pain. Sectin 9 - Traveling O. I get n pain when travefmg. 1. I get sme pain when traveling but nne f my usual frms f travel make it any WOISe. 2. I get extra pain while traveling but it des nt cmpel me t seek alternate frms f travel. 3. I get extra pain while traveling which cmpels t seek alternative frms f travel. 4. Pain restricts me t shrt necessary jurneys under % hur. 5. Pain restricts au frms f travel. Sectin 10 - Changing Degree f Pain O. My pain is rapidly getting better. 1. My pain fluctuates but is definitely getting better. 2. My pain seems t be getting better but imprvement is slw. 3. My pain is neither getting better r wrse. 4. My pain is gradually wrsening. 5. My pain is rapidly wrsening. TOTAL

3 Lwer Extremity Functinal Scale We are interested in knwing whether yu are having any difficulty at all with the activities listed belw because f yur lwer limb prblem fr which yu are currently seeking attentin. Please check (..J)an answer fr each activity.. --J, '.J J Extreme Difficulty Or Unable Quite a A Little t Perfrm Bit f Mderate Bit f N Activities Activity Difficultv Difficulty Difficulty Difficulty Any f yur usual wrk, husehld, r schl activities Yur usual hbbies, recreatinal r sprting activities Getting int r ut f the bath Walking between rms Putting n yur shes r scks Squatting Lifting an bject, like a bag f grceries frm the flr Perfrming light activities arund yur Hme Perfrming heavy activities arund yur Hme Getting int r ut f a car Walking 2 blcks Walking a mile Ging up r dwn 10 stairs (abut 1 flight f stairs) Standing fr 1 hur Sitting fr 1 hur Running n even grund Running n uneven grund Making sharp turns while running fast Hpping Rlling ver in bed Binkley JM, Stratfrd POW, Ltt SA, Riddle DL. The lwer extremity functinal scale (LEFS): Scale develpment, measurement prperties, and clinical applicatin. Physical Therapy 1999;79: Patient name: Scre 180 Signature: MDC(minimumdetectablechange) = 9 pts : Errr +1-5 scalepints

4 Upper Extremity Functinal Scale 1 We are interested in knwing whether yu are having any difficultyat all with the activitieslisted belw because f vur UDDerlimb prblem fr which yu are currently seeking attentin. Please check (---J)an answer fr each activity. Tday, d vu r wuld vu have any difficultyat all with: Extreme Difficulty Or Unable Quite a A Little t Perfrm Bit f Mderate Bit f N Activities Activitv Difficultv Difficultv Difficulty Difficulty Any f yur usualwrk,husehld,r schl activities Yur usualhbbies,recreatinalr sprtingactivities Liftinga bagf grceriest waist level Liftinga bagf grceriesabveyur head Grmingyurhair Pushingup n yurhands(e.g.,frm bathtubr chair) Preparingfd (e.g.,peeling,cutting) Driving Vacuuming,sweeping,r raking Dressing Dingup buttns Using tls r appliances Openingdrs Cleaning Tying r lacing"shes Sleeping Launderingclthes(e.g.,washing, irning,flding) Openinga jar Thrwinga ball Carryinga smallsuitcasewith yur affected limb) Stratfrd P, Binkley JM, Stratfrd POW. Develpment and initial validatin f the upper extremity functinal index. Physitherapy Canada Fall 2001; ,281. Patient name: Signature: : Scre /80 MDC (minimum detectable change) = 9 pts Errr +/- 5 scale pints

5 : Name: Draw lcatin f yur pain n bdy utlines Ache MrV\ M Burning Numbness am m Pins and Needles... Stabbing /11I11// /III Other XX>OO< ;00( Back Frnt What is yur TYPICAL r AVERAGE pain? N Pain Unbearable Pain ----

6 NAME Primary cmplaint - YFFORM 1. Please indicate yur usual level f pain during the past week: N pain \Vrst pssible pain 2. Des pain, numbness, tingling r weakness extend int yur leg (frm the lw back) &/r arm (frm the neck)? Nne f the time All f the time 3. Hw wuld yu rate yur general health?. Pr (lo-x) Excellent 4. If yu had t spend the rest f yur life with yur cnditin as it is right nw, hw wuld yu feel abut it? Delighted Terrible 5. Hw anxius (eg. tense, uptight, irritable, fearful, difficulty in cncentrating/ relaxing) yu have been feeling during the past week: Nt at all Extremely anxius 6. Hw much yu have been able t cntrl (i.e., reduce/help) yur pain/cmplaint n yur wn during the past week: I can reduce it I can't reduce it at all 7. Please indicate hw depressed (eg. Dwn-in-the-dumps, sad, dwnhearted,in lw spirits, pessimistic, feelings f hpelessness) yu have been feeling in the past week: Nt depressed at all Extremely depressed 8. On a scale f 0 t 10, hw certain are yu that yu will be ding nrmal activities r wrking in six mnths? Very certain Nt certain at all 9. I can d light wrk fr an hur? Cmpletely agree Cmpletely disagree 10. I can sleep at night Cmpletely agree Cmpletely disagree 11. An increase in pain is an indicatin that I shuld stp what I am ding until the pain decreases. Cmpletely disagree Cmpletely agree 12. Physical activity makes my pain wrs~? Cmpletely disagree Cmpletely agree 13. I shuld nt d my nrmal activities including wrk with my present pain. Cmpletely disagree Cmpletely agree Please sign yur name

7 PRIVACY PRACTICES ACKNOWLEDGEMENT PATIENTACKNOWLEDGEMENTFORM I have received the Ntice f PrivacyPractices and I have been prvided an pprtunity t review it. Name Birthdate Signature INFORMED CONSENT I understand that payment is required at time f service. Mst medical insurances and credit cards are accepted. I understand and agree that health accident insurance pliciesare an agreement between an insurance carrier and myself. Furthermre, I understand that this chirpractic ffice willprepare any necessary reprts and frms t assist me in making cllectins frm the insurance cmpany and that any amunt authrized t be paid directly t this chirpracticffice willbe credited t my accunt. Hwever,I clearly understand and agree that all services rendered t me are charged directly t me and that I am persnally respnsible fr payment. I als understand that if I suspend r terminate my care and treatment, any fees fr prfessinal services rendered me willbe immediatelydue and payable. I further agree t pay all cllectinagency fees, attrney fees, curt fees and ther related csts incurred in the cllectin f my accunt. I understand that, like in all health care prcedures, risk is invlved. The risks including, but nt limitedt, sprains, fractures, dislcatins, disk injury, strke, ther injuries, hwever remte are pssible after receiving care frm any chirpractr. I have been given the chance t questin my dctr n theses risks, and understanding risks are pssible, I cnsent t treatment. I authrize the release f medical recrds t the physicianr physicianst wh I may be referred. I authrize the release f any medical infrmatin necessary t prcess insurance claims. I authrize and assign payment f medical benefits fr Thmas E. Smith, DC. Patient Signature Guardian r Spuse's Signature Authrizing Care Taken By