Self-Assessment: Neck & Back Pain

Self-Assessment: Neck & Back Pain The following questions will help you learn if you can benefit from therapeutic intervention to address your neck or back pain. For each question, select the choice that best applies to you. Do you have neck or back pain that limits you performing daily functional activities? (e.g.: dressing, bathing, toileting) Yes No Do you have neck or back pain that restricts you from performing any recreational activities? (e.g.: hiking, sports) Yes No Do you have neck or back pain that restricts you from performing any daily household activities? (e.g.: laundry, vacuuming, cleaning) Yes No Do you have pain at night that significantly interferes with your sleeping? Yes No Do you have any of the following symptoms in your arms or legs: pain, burning, shooting pain, ache/numbness, tingling? Yes No Have you noticed weakness in your arms or legs? Yes No Have you noticed significant loss of balance or difficulty walking? Yes No Do you have a weakness in the foot or “foot drop?” Yes No Have you experienced loss of bowel or bladder control? Yes No Orthopedic Services Self-Assessment: Hip & Knee Pain Self-Assessment: Neck & Back Pain