Forms Oswestry Neck Patient Form Name(Required) First Last Date(Required) DoctorHospitalThis questionnaire is designed to help us better understand how your neck pain affects your ability to manage in everyday life. Please choose ONLY ONE option by placing an X next to the option that most closely describes your present day situation. Please ensure you complete all 10 questions.1. With regards to Pain Intensity, which of the following options applies to you most at this time: 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 worst imaginable at the moment. 2. Regarding Personal Care (washing, dressing, etc.), which of the following options applies to you most at this time: I can look after myself without causing extra neck pain. I can look after myself normally but it causes extra neck pain. It is painful to look after myself and I am slow and careful. I need some help but can manage most of my personal care. I need help every day in most aspects of my personal care. I do not get dressed, I wash with difficulty, and I stay in bed. 3. With regards to Lifting, which of the following options applies to you most at this time: 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 conveniently placed (i.e. on a table). Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned. I can only lift very light weights. I cannot lift or carry anything at all. 4. With regards to Reading, which of the following options applies to you most at this time: I can read as much as I want to with no pain in my neck. I can read as much as I want to with slight pain in my neck. I can read as much as I want to with moderate pain in my neck. I cannot read as much as I want because of moderate pain in my neck. I can hardly read at all because of severe pain in my neck. I cannot read at all. 5. With regards to Headaches, which of the following options applies to you most at this time: I have no headaches at all. I have slight headaches that come infrequently. I have moderate headaches that come infrequently. I have moderate headaches that come frequently. I have severe headaches that come frequently. I have headaches almost all the time. 6. Regarding Concentration, which of the following options applies to you most at this time: I can concentrate fully when I want to with no difficulty. I can concentrate fully when I want to with slight difficulty. I have a fair degree of difficulty in concentrating when I want to. I have a lot of difficulty in concentrating when I want to. I have a great deal of difficulty in concentrating when I want to. I cannot concentrate at all. 7. Regarding Work, which of the following options applies to you most at this time: I can do as much work as I want to. I can 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 work at all. I cannot do any work at all. 8. With regards to Driving, which of the following options applies to you most at this time (if applicable): I can drive my car without any neck pain. I can drive my car as long as I want, with slight pain in my neck. I can drive my car as long as I want, with moderate pain in my neck. I cannot drive my car as long as I want because of moderate pain in my neck. I can hardly drive at all because of severe pain in my neck. I cannot drive my car at all. 9. With regards to Sleeping, which of the following options applies to you most at this time: I have no trouble sleeping. My sleep is slightly disturbed (less than 1 hour sleepless). My sleep is mildly disturbed (1-2 hours sleepless). My sleep is moderately disturbed (2-3 hours sleepless). My sleep is greatly disturbed (3-5 hours sleepless). My sleep is completely disturbed (5-7 hours sleepless). 10. With regards to Recreation, which of the following options applies to you most at this time: I am able to engage in all my recreation activities with no neck pain at all. I am able to engage in all my recreation activities, with some pain in my neck. I am able to engage in most, but not all, of my usual recreation activities because of pain in my neck. I am able to engage in a few of my recreation activities because of pain in my neck. I can hardly do any recreation activities because of pain in my neck. I cannot do any recreation activities at all.
