*****This is a simulation page and no data will be transmitted.*****

This questionnaire has been designed to give the doctor information as to how your neck problems have affected your ability to manage in everyday life.

Please answer every section and mark in each section ONLY THE ONE which applies to you.

We realize you may consider that two of the statements in any one section relate to you.

PLEASE JUST MARK THE ONE WHICH MOST CLEARLY DESCRIBES YOUR PROBLEM.

 
 
 
 
 
Pain Intensity
 
 
 
 
 
 
Personal Care
(washing, dressing, etc.)
 
 
 
 
 
 
Lifting
 
 
 
 
 
 
Reading
 
 
 
 
 
 
Headaches
 
 
 
 
 
 
Concentration
 
 
 
 
 
 
Work
 
 
 
 
 
 
Driving
 
 
 
 
 
 
Sleeping
 
 
 
 
 
 
Recreation
 

IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
 
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.