Functional Questionnaire

We will present you with a series of questions that are standard assessments based on the location of the majority of your symptoms. They are standard assessments of your function and can help to monitor change and progress.

Patient ID:*

Last 4 digits of your phone number:
Please pick the area you want to focus on the most or you have the most issue with:*
Please rate your level of pain with activity:*
0 = NO PAIN 10 = VERY SEVERE PAIN
Pain Intensity*
- 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 worse imaginable at the moment.
Personal Care (washing, dressing, etc)*
- I can look after myself normally without 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 self-care.
- I need help every day in most aspects of self-care.
- I cannot get dressed, wash with difficulty, and stay in bed
Lifting*
- I can lift heavy weights without extra pain.
- I can lift heavy weights but it gives me extra pain.
- Pain prevents me from lifting heavy weights off the floor but I can manage if they are on a table.
- Pain prevents me from lifting heavy weights but I can manage if they are conveniently placed.
- I can lift only very light weights.
- I cannot lift or carry anything at all.
Headache*
- 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 infrequently
- I have headaches almost all the time.
Recreation*
- I can engage in all my recreational activities without pain.
- I can engage in my recreational activities with some pain
- I can engage in most but not all of my usual recreational activities because of my neck pain
- I can engage in a few of my usual recreational activities with some neck pain
- I can hardly do any recreational activities because of neck pain
- I can't do any recreational activities at all
Reading*
- I can read as much as I want with no pain in my neck
- I can read as much as I want with slight neck pain.
- I can read as much as I want with moderate neck pain
- I can't read as much as I want because of moderate neck pain.
- I can hardly read at all because of severe neck pain.
- I cannot read at all because of neck pain.
Work*
- I can do as much 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 usual work at all.
- I can't do any work at all.
Sleeping*
- Pain does not prevent me from sleeping well.
- My sleep is slightly disturbed (<1 hr sleep loss).
- My sleep is mildly disturbed (1-2 hr sleep loss).
- My sleep is moderately disturbed (2-3 hr sleep loss).
- My sleep is greatly disturbed (3-4 hr sleep loss).
- My sleep is completely disturbed (5-7 hr sleep loss).
Concentration*
- I can concentrate fully when I want with no difficulty
- I can concentrate fully when I want with slight difficulty
- I have a fair degree of difficulty concentrating when I want
- I have a lot of difficulties concentrating when I want
- I have great difficulty concentrating when I want.
- I cannot concentrate at all
Driving*
- I can drive my car without 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 my car at all because of severe neck pain
- I can't drive my car at all
Any of your usual work, housework or school activities*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Your usual hobbies, recreational or sporting activities*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Getting into or out of the bath*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Walking between rooms*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Putting on your shoes or socks*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Squatting*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Lifting an object, like a bag of groceries from the floor*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Performing light activities around your home*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Performing heavy activities around your home*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Getting into or out of a car*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Walking 2 blocks*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Walking a mile*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Going up or down 10 stairs (about 1 flight of stairs)*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Standing for 1 hour*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Sitting for 1 hour*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Running on even ground*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Running on uneven ground*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Making sharp turns while running fast*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Hopping*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Rolling over in bed*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Pain Intensity*
- I can tolerate the pain I have without having to use pain medication.
- The pain is bad, but I can manage without having to take pain medication.
- Pain medication provides me with complete relief from pain.
- Pain medication provides me with moderate relief from pain.
- Pain medication provides me with little relief from pain.
- Pain medication has no effect on my pain.
Personal Care (washing, dressing, etc.)*
- I can take care of myself normally without causing increased pain.
- I can take care of myself normally, but it increases my pain.
- It is painful to take care of myself, and I am slow and careful.
- I need help, but I am able to manage most of my personal care.
- I need help every day in most aspects of my care.
- I do not get dressed, wash with difficulty, and stay in bed.
Lifting*
- I can lift heavy weights without increased pain.
- I can lift heavy weights, but it causes increased pain.
- Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (eg, 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 only very light weights.
- I cannot lift or carry anything at all.
Walking*
- Pain does not prevent me from walking any distance.
- Pain prevents me from walking more than 1 mile.
- Pain prevents me from walking more than 1/2 mile.
- Pain prevents me from walking more than 14 mile.
- I can only walk with crutches or a cane.
- I am in bed most of the time and have to crawl to the toilet.
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 1 hour.
- Pain prevents me from sitting more than 1/2 hour.
- Pain prevents me from sitting more than 10 minutes.
- Pain prevents me from sitting at all.
Standing*
- I can stand as long as I want without increased pain.
- I can stand as long as I want but, it increases my pain.
- Pain prevents me from standing more than 1 hour.
- Pain prevents me from standing more than 1/2 hour.
- Pain prevents me from standing more than 10 minutes.
- Pain prevents me from standing at all.
Sleeping*
- Pain does not prevent me from sleeping well.
- I can sleep well only by using pain medication.
- Even when I take pain medication, I sleep less than 6 hours.
- Even when I take pain medication, I sleep less than 4 hours,
- Even when I take pain medication, I sleep less than 2 hour
- Pain prevents me from sleeping at all.
Social Life*
- My social life is normal and does not increase my pain.
- My social life is normal, but it increases my level of pain.
- Pain prevents me from participating in more energetic activities (eg, sports, dancing).
- Pain prevents me from going out very often.
- Pain has restricted my social life to my home.
- I have hardly any social life because of my pain.
Traveling*
- I can travel anywhere without increased pain.
- I can travel anywhere, but it increases my pain.
- My pain restricts my travel over 2 hours.
- My pain restricts my travel over 1 hour.
- My pain restricts my travel to short necessary journeys under 1/2 hour.
- My pain prevents all travel except for visits to the physician/therapist or hospital.
Employment / Homemaking*
- My normal homemaking/job activities do not cause pain.
- My normal homemaking/job activities increase my pain, but I can still perform all that is required of me.
- I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (eg, lifting, vacuuming).
- Pain prevents me from doing anything but light duties.
- Pain prevents me from doing even light duties.