KAISER PERMANENTE SPINE

Transcription

1 KAISER PERMANENTE SPINE The following forms are specially designed to give your doctor valuable information about the health of your spine. The same way an EKG gives us information about your heart. It is very important that you answer all questions to the best of your ability. These forms will be given to you on your initial consultation with your doctor and subsequently (if you have surgery) on your visits to the clinic as well as 3 months, 6 months, 12 months and 24 months post-surgery. In some cases, in which a visit to the office is not needed, then the answers to these forms can be shared via telephone conversations with our staff.

2 Name: Please take the time to answer the following question about your health. This form is important since it allows us to monitor your progress as we provide a treatment plan for you. SCOLIOSIS SPINE QUESTIONNAIRE (Scoliosis Form) MRN: DATE: NOTE: 1. These questionnaires are used to evaluate your current symptoms. 2. You will receive these questionnaires on every visit to our office and at 3, 6, 12, 24 months after your surgery to evaluate your progress and the outcome from surgery. 3. Please take the time to fill it completely and accurately. For the following questions, please indicate your level of pain by putting an X on the line below. What is your average pain level in your lower back, if any? What is your average pain level in your legs and feet, if any? Patient satisfaction about surgery (Choose ONLY ONE ANSWER) 1 I did not have surgery 2 Surgery met my expectation 3 I did not improve as much as I hoped but would undergo the same operation for the same results 4 Surgery helped but I would not undergo the same operation for the same results 5 I am the same or worse as compared to before the surgery 1

3 Please answer the following questions placing a circle on the number which describes your pain intensity and other functions. Only ONE CHOICE in each section. Section 1- Pain Intensity 0. The pain comes and goes and is very mild 1. The pain is mild and does not vary much 2. The pain comes and goes and is moderate 3. The pain is moderate and does not vary much 4. The pain come and goes and is severe 5. The pain is severe and does not vary much Section 2- Personal Care (Washing, Dressing, etc.) 0. I would not have to change my way of washing or dressing in order to avoid pain 1. I do not normally change my way of washing or dressing even though it causes some pain 2. Washing and dressing increases the pain but I manage not to change my way of doing it. 3. Washing and dressing increase the pain and I find it necessary to change my way of doing it 4. Because of the pain I am unable to do some washing and dressing without help 5. Because of the pain I am unable to do any washing and dressing without help. Section 3- Lifting 0. I can lift heavy weights without extra pain 1. I can lift heavy weights but it gives extra pain 2. Pain prevents me lifting heavy weights off the floor 3. Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g., on a table. 4. Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. 5. I can only lift very light weights at most. Section 4- Walking 0. I have no pain on walking 1. I have some pain on walking but it does not increase with distance 2. I cannot walk more than 1 mile without increasing pain. 3. I cannot walk more than ½ mile without increasing pain 4. I cannot walk more than ¼ mile without increasing pain 5. I cannot walk at all without increasing pain. Section 5- Sitting 0. I can sit in any chair as long as I like 1. I can sit only in my favorite chair as long as I like 2. Pain prevents me from sitting more than 1 hour 3. Pain prevents me from sitting more than ½ hour 4. Pain prevents me from sitting more than 10 minutes 5. I avoid sitting because it increases pain immediately. Section 6- Standing 0. I can stand as long as I want without pain 1. I have some pain on standing but it does not increase with time 2. I cannot stand for longer than 1 hour without increasing pain 3. I cannot stand for longer than ½ hour without increasing pain 4. I cannot stand for longer than 10 minutes without increasing pain 5. I avoid standing because it increases the pain immediately. Section 7- Sleeping 0. I get no pain in bed 1. I get pain in bed but it does not prevent me from sleeping well. 2. Because of pain my normal sleep is reduced by less than one-quarter 3. Because of pain my normal sleep is reduced by less than one-half 4. Because of pain my normal sleep is reduced by less than three-quarters 5. Pain prevents me from sleeping at all Section 8- Social Life 0. My social life is normal and gives me no pain 1. My social life is normal but it increases the degree of pain 2. Pain has no significant effect on my social life apart from limiting my more energetic interests e.g., dancing, etc. 3. Pain has restricted my social life and I do not go out very often 4. Pain has restricted my social life to my home 5. I have hardly any social life because of the pain Section 9- Traveling 0. I get no pain when traveling 1. I get some pain when traveling but none of my usual forms of travel make it any worse 2. I get extra pain while traveling but it does not compel me to seek alternate forms of travel 3. I get extra pain while traveling which compels me to seek alternate forms of travel 4. Pain restricts me to short necessary journeys under ½ hour 5. Pain restricts all forms of travel Section 10- Changing Degree of Pain 0. My pain is rapidly getting better 1. My pain is fluctuating but is definitely getting better 2. My pain seems to be getting better but improvement is slow 3. My pain is neither getting better or worse 4. My pain is gradually worsening 5. My pain is rapidly worsening For Office Use Only: Oswestry Score = x 2 = % 2

4 OWN HEALTH QUESTIONS (EQ5D) Place a circle on the number for each category that indicates which statements best describe your own health state today. Mobility 1. I have no problems in walking about 2. I have slight problems in walking about 3. I have moderate problems in walking about 4. I have severe problems in walking about 5. I am unable to walk about Self-Care 1. I have no problems washing or dressing myself 2. I have slight problems washing or dressing myself 3. I have moderate problems washing or dressing myself 4. I have severe problems washing or dressing myself 5. I am unable to wash or dress myself Usual Activities (e.g., work, study, housework, family, or leisure activities) 1. I have no problems doing my usual activities 2. I have slight problems doing my usual activities 3. I have moderate problems doing my usual activities 4. I have severe problems doing my usual activities 5. I am unable to do my usual activities Pain/Discomfort 1. I have no pain or discomfort 2. I have slight pain or discomfort 3. I have moderate pain or discomfort 4. I have severe pain or discomfort 5. I have extreme pain or discomfort Anxiety/Depression 1. I am not anxious or depressed 2. I am slightly anxious or depressed 3. I am moderately anxious or depressed 4. I am severely anxious or depressed 5. I am extremely anxious or depressed For Office Use Only Mobility Self-care Usual Activity Pain/Discomfort Anxiety/Depression EQ5D Score 3

5 OWN HEALTH SCALE (EQ5D VAS) To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line at whichever point on the scale indicates how good or bad your health state is today or by entering a number between 100 (best state) and 0 (worst state) in the form field. Best imaginable health state For Official Use Only EQ5D VAS Score Worst imaginable health state 4

6 INSTRUCTIONS: We are carefully evaluating the condition of your back and it is IMPORTANT THAT YOU ANSWER EACH OF THESE QUESTIONS YOURSELF. Please CIRCLE THE ONE BEST ANSWER TO EACH QUESTION. 1. Which one of the following best describes the amount of pain you have experienced during the past 6 months? 5. None 4. Mild 3. Moderate 2. Moderate to severe 1. Severe 2. Which one of the following best describes the amount of pain you have experienced over the last month? 5. None 4. Mild 3. Moderate 2. Moderate to severe 1. Severe 3. During the past 6 months have you been a very nervous person? 5. None of the time 4. A little of the time 3. Some of the time 2. Most of the time 1. All of the time 4. If you had to spend the rest of your life with your back shape as it is right now, how would you feel about it? 5. Very happy 4. Somewhat happy 3. Neither happy nor unhappy 2. Somewhat unhappy 1. Very unhappy 5. What is your current level of activity? 6. How do you look in clothes? 5. Bedridden 4. Primarily no activity 3. Light labor and light sports 2. Moderate labor and moderate sports 1. Full activities without restriction 5. Very good 4. Good 3. Fair 2. Bad 1. Very bad 5

7 7. In the past 6 months have you felt so down in the dumps that nothing could cheer you up? 5. Very often 4. Often 3. Sometimes 2. Rarely 1. Never 8. Do you experience back pain when at rest? 5. Very often 4. Often 3. Sometimes 2. Rarely 1. Never 9. What is your current level of work/school activity? % normal 4. 75% normal 3. 50% normal 2. 25% normal 1. 0% normal 10. Which of the following best describes the appearance of your trunk; defined as the human body except for the head and extremities? 5. Very good 4. Good 3. Fair 2. Poor 1. Very Poor 11. Which one of the following best describes your pain medication use for back pain? 5. None 4. Non-narcotics weekly or less (e.g., aspirin, Tylenol, Ibuprofen) 3. Non-narcotics daily 2. Narcotics weekly or less (e.g. Tylenol III, Lorcet, Percocet) 1. Narcotics daily 12. Does your back limit your ability to do things around the house? 5. Never 4. Rarely 3. Sometimes 2. Often 1. Very Often 6

8 13. Have you felt calm and peaceful during the past 6 months? 5. All of the time 4. Most of the time 3. Some of the time 2. A little of the time 1. None of the time 14. Do you feel that your back condition affects your personal relationships? 5. None 4. Slightly 3. Mildly 2. Moderately 1. Severely 15. Are you and/or your family experiencing financial difficulties because of your back? 5. Severely 4. Moderately 3. Mildly 2. Slightly 1. None 16. In the past 6 months have you felt down hearted and blue? 5. Never 4. Rarely 3. Sometimes 2. Often 1. Very often 17. In the last 3 months have you taken any days off of work, including household work, or school because of back pain? 5. 0 days 4. 1 day 3. 2 days 2. 3 days 1. 4 or more days 18. Does your back condition limit your going out with friends/family? 5. Never 4. Rarely 3. Sometimes 2. Often 1. Very often 7

9 19. Do you feel attractive with your current back condition? 5. Yes, very 4. Yes, somewhat 3. Neither attractive nor unattractive 2. No, not very much 1. No, not at all 20. Have you been a happy person during the past 6 months? 5. None of the time 4. A little of the time 3. Some of the time 2. Most of the time 1. All of the time 21. Are you satisfied with the results of your back management? 5. Very satisfied 4. Satisfied 3. Neither satisfied nor unsatisfied 2. Unsatisfied 1. Very unsatisfied 22. Would you have the same management again if you had the same condition? 5. Definitely yes 4. Probably yes 3. Not sure 2. Probably not 1. Definitely not Thank you for completing this questionnaire. 8

10 For Office Use Only Domain Answers/Questions Sum of Responses (A) Questions Answered (B) Score (A/B) Activity (5) Pain (5) Appearance (5) Mental (5) Subtotal (20) Satisfaction (2) Total TOTAL (22) For Office Use Only Activity Pain Appearance Mental Satisfaction Total SRS 22r Score 9