Healthy Spine Program Pre-Assessment Clinical Form

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Your Personal Information

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This questionnaire has been designed to give the PainWISE Healthy Spine Clinical team information as to how to assist back pain and how it affects your everyday life. Please answer every question section, and select the options that best describes your condition today.

Your Name(Required)

First Name Surname

I/C Number(Required)

Employee Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Whatsapp Mobile (Please include your country code, e.g. +60 12 234 2345)(Required)

Your Email Address(Required)

Enter Email Confirm Email

A little bit about you

Main Location of your pain (tick all your affected areas)

Neck

Upper back

Middle of the back

Lower back

Hips

My pain moves to other parts of my body (tick all your affected areas)

Neck

Upper back

Middle of the back

Lower back

Hips

Shoots down my arms

Shoots down my legs

In the last month how often has your pain occurred

Less than once a month

Once every 2 weeks

Once a week

Everyday

What is the worse time of day for you to experience this pain:

First thing in the morning

Morning

Afternoon

Evening

How long have you had this pain for?

Last 12 months

Last 6 months

Last 3 months

Last 1 month

Last few days only

What do you think is contributing to your pain?

Section 1 – Pain Intensity

I can tolerate the pain I have without having to use pain medication.

The pain is bad but I manage without having to take pain medication.

Pain medication provides me complete relief from pain.

Pain medication provides me moderate relief from pain.

Pain medication provides me little relief from pain.

Pain medication has no effect on the pain.

Section 2 – 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.

Section 3 – 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 weights are conveniently positioned, e.g. 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.

Section 4 - Walking

Pain does not prevent me walking any distance.

Pain prevents me walking more than 1 kilometre.

Pain prevents me walking more than ½ kilometre.

Pain prevents me walking more than ¼ kilometre.

I can only walk using crutches or a cane.

I am in bed most of the time and have to crawl to the toilet.

Section 5 - Sitting

I can sit in any chair as long as I like.

I can only sit in my favourite chair as long as I like.

Pain prevents me sitting more than 1 hour.

Pain prevents me from sitting more than ½ hour.

Pain prevents me from sitting more than 10 mins.

Pain prevents me from sitting at all.

Section 6 – Standing

I can stand as long as I want without increased pain.

I can stand as long as I want but increases my pain.

Pain prevents me from standing for more than 1 hour.

Pain prevents me from standing for more than ½ hour.

Pain prevents me from standing for more than 10 mins.

Pain prevents me from standing at all.

Section 7 – 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 hours.

Pain prevents me from sleeping at all

Section 8 – 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 (ex sports, dancing, etc.)

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.

Section 9 – Traveling (to work, holiday, long drives etc)

I can travel anywhere without increased pain.

I can travel anywhere but it increases my pain.

Pain restricts travel over 2 hours.

Pain restricts travel over 1 hour.

Pain restricts my travel to short necessary journeys under ½ hour.

Pain prevents all travel except for visits to the doctor/therapist or hospital.

Section 10 – 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 (ex. Lifting, vacuuming).

Pain prevents me from doing anything but light duties.

Pain prevents me from doing even light duties.

Pain prevents me from performing any job/homemaking chores.

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