Cardiff and Vale Spinal Unit Mr M J H McCarthy FRCS
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1 Cardiff and Vale Spinal Unit Mr M J H McCarthy FRCS NECK / ARM PAIN QUESTIONNAIRE Affix Patient Label This document contains a series of standard assessments that are very useful in helping us assess your spinal problem. The questions also help to determine whether or not there has been any benefit from the treatments you have received. Todays Date: Where is your pain located? Please shade the problem areas on the diagram and mark the worst affected area. Please mark a point on the line between the faces to indicate how much NECK PAIN you have felt OVER THE LAST MONTH. Please mark a point on the line between the faces to indicate how much ARM PAIN you have felt OVER THE LAST MONTH. Version 1 Feb 2012 MJHM Neck Q 1
2 PLEASE ANSWER BY CIRCLING THE WORDS THAT BEST FIT YOUR PROBLEM. Which pain is the worse pain? NECK PAIN ARM PAIN How long have you had your present pain? Less than 7 weeks 7-12 weeks More than 12 weeks Has it worsened over time? YES NO Do you feel unsteady on your feet? YES NO How far can you walk before you have to stop? 100 yards 200 yards 400 yards 800 yards 1 mile or more Are you experiencing any numbness, weakness or tingling? YES NO What triggered your pain? Accident at work Following an illness Accident at Home Following Surgery Car Accident Pain just began Other: Have you had previous spine surgery? YES NO How does the pain affect your sleep? Trouble falling asleep Medications needed to fall asleep Awakened by pain The following is a list of things that may improve or worsen your pain. Please check the appropriate box as it affects your pain. Improves Worsens Improves Worsens Movement Medication No movement Walking Rest / Sleep Sitting Massage Standing Mild Exercise Lying down What is your current status? E.g. Student, housewife, working, retired, disabled How much time have you lost from work in the last year? None less than a week one to three weeks three to six weeks six to twelve weeks three to six months six to twelve months more than one year Are you receiving disability Benefit? YES NO Is there any personal injury claim pending regarding your back pain? YES NO Have you had to retire because of your back? YES NO Version 1 Feb 2012 MJHM Neck Q 2
3 Neck Disability Index (NDI) Could you please complete this questionnaire? It is designed to give us information as to how your neck (or arm) trouble has affected your ability to manage in everyday life. Please answer every section. Mark ONE box only in each section that most closely describes you over the last month. Section 1 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 worst imaginable at the moment. Section 6 Work 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 can t do any work at all. Section 2 Personal Care (washing, dressing, etc.) I can look after myself without causing extra pain. I can look after myself normally but it is very painful. It is painful to look after myself and I am slow and careful. I need some help but manage most of my personal care. I need help everyday in most aspects of self-care. I do not get dressed, wash with difficulty and stay in bed. Section 3 Lifting I can lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g. on a table. Pain prevents me from lifting heavy weights, but I can mange 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 Reading 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 can t 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. Section 5 Headaches 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 of the time. Section 7 Concentration 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. Section 8 Driving (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 neck pain. I can t 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 can t drive my car at all. Section 9 Sleeping I have no trouble sleeping. My sleep is slightly disturbed (less than 1 hour). My sleep is mildly distrubed (1-2 hrs sleepless). My sleep is moderately distrubed (2-3 hrs sleepless). My sleep is greatly distrubed (3-5 hrs sleepless). My sleep is completely distrurbed (5-7 hrs sleepless). Section 10 Recreation I am able to engage in all my recreational activities with no neck pain at all. I am able to engage in all of my recreational activities with some neck pain. I am able to engage in most but not all of my usual recreation activities beacsue of pain in my neck. I am able to engage in few of my recreational activities beacsue of pain in my neck. I can hardly do any recreational activities because of pain in my neck. I can t do any recreational activities at all. Version 1 Feb 2012 MJHM Neck Q 3
4 Version 1 Feb 2012 MJHM Neck Q 4
5 This section is for post operative patients only Please mark a point on the line below to indicate how much you think your pain improved following your original operation. The far left end indicates complete pain relief (the operation worked very well) and the far right end indicates no pain relief (the operation did not help your pain). Neck Pain Complete Pain Relief No Pain Relief Arm Pain Complete Pain Relief No Pain Relief How far can you walk? 100 yards 200 yards 400 yards 800 yards 1 mile or more How would you rate your overall outcome from surgery? Good Fair Poor Would you have the operation again? Yes No Not applicable Please rate your % improvement in neck pain following the operation < >76 Please rate your % improvement in arm pain following the operation < >76 Are your daily activities restricted because of your neck / arm pain? Yes great Yes some Not restricted How much pain medication do you require for your neck / arm? Regular As required None Did you return to employment / work? No Yes Limited Yes Full Not applicable Thank you for your time completing this questionnaire. Version 1 Feb 2012 MJHM Neck Q 5
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