Outcome Forms

Choose your form:

Functional outcome assessments are tools we can use to score how your injury or symptoms are affecting your life. Each form is specific to a general area and contains questions that may (or may not) apply to you. Your therapist will guide you to which form applies to you and let you know when to fill one out.

Neck Index
This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.
Name*
First Last
Your Physical Therapist*
- Dr. Paul Ochoa
- Dr. Monique Dupree
- Dr. Nick Langelotti
Your Date of Birth*
Pain Intensity*
- Does Not Apply
- I have no pain at the moment.
- The pain is very mild at the moment.
- The pain comes and goes and is moderate.
- 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.
Personal Care*
- Does Not Apply
- I can look after myself normally without causing extra pain.
- I can look after myself normally but it causes extra pain.
- It is painful to look after myself and I am slow and careful.
- I need some help but I manage most of my personal care.
- I need help every day in most aspects of self care.
- I do not get dressed, I wash with difficulty and stay in bed.
Sleeping*
- Does Not Apply
- 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).
Lifting*
- Does Not Apply
- I can lift heavy weights without extra pain.
- I can lift heavy weights but it causes 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 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.
Reading*
- Does Not Apply
- I can read as much as I want with no neck pain.
- I can read as much as I want with slight neck pain.
- I can read as much as I want with moderate neck pain.
- I cannot read as much as I want because of moderate neck pain.
- I can hardly read at all because of severe neck pain.
- I cannot read at all because of neck pain.
Driving*
- Does Not Apply
- I can drive my car without any neck pain.
- I can drive my car as long as I want with slight neck pain.
- I can drive my car as long as I want with moderate neck pain.
- I cannot drive my car as long as I want because of moderate neck pain.
- I can hardly drive at all because of severe neck pain.
- I cannot drive my car at all because of neck pain.
Concentration*
- Does Not Apply
- I can concentrate fully when I want with no difficulty.
- I can concentrate fully when I want with slight difficulty.
- I have a fair degree of difficulty concentrating when I want.
- I have a lot of difficulty concentrating when I want.
- I have a great deal of difficulty concentrating when I want.
- I cannot concentrate at all.
Recreation*
- Does Not Apply
- I am able to engage in all my recreation activities without neck pain.
- I am able to engage in all my usual recreation activities with some neck pain.
- I am able to engage in most but not all my usual recreation activities because of neck pain.
- I am only able to engage in a few of my usual recreation activities because of neck pain.
- I can hardly do any recreation activities because of neck pain.
- I cannot do any recreation activities at all.
Work*
- Does Not Apply
- I can do as much work as I want.
- I can only do my usual work but no more.
- I can only 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.
Headaches*
- Does Not Apply
- I have no headaches at all.
- I have slight headaches which come infrequently.
- I have moderate headaches which come infrequently.
- I have moderate headaches which come frequently.
- I have severe headaches which come frequently.
- I have headaches almost all the time.
Pain Intensity Hidden Number
Personal Care Hidden Number
Sleeping Hidden Number
Lifting Hidden Number
Reading Hidden Number
Driving Hidden Number
Concentration Hidden Number
Recreation Hidden Number
Work Hidden Number
Headaches Hidden Number
Neck Index Total
Index Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things*
- Not at all
- Several Days
- More than half days
- Nearly every day
Feeling down, depressed or hopeless*
- Not at all
- Several Days
- More than half days
- Nearly every day
PHQ 2 Score

Back Index
This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.
Name*
First Last
Your Physical Therapist*
- Dr. Paul Ochoa
- Dr. Monique Dupree
- Dr. Nick Langelotti
Your Date of Birth*
Pain Intensity*
- Does Not Apply
- The pain comes and goes and is very mild.
- The pain is mild and does not vary much.
- The pain comes and goes and is moderate.
- The pain is moderate and does not vary much.
- The pain comes and goes and is very severe.
- The pain is very severe and does not vary much.
Personal Care*
- Does Not Apply
- I do not have to change my way of washing or dressing in order to avoid pain.
- I do not normally change my way of washing or dressing even though it causes some pain.
- Washing and dressing increases the pain but I manage not to change my way of doing it.
- Washing and dressing increases the pain and I find it necessary to change my way of doing it.
- Because of the pain I am unable to do some washing and dressing without help.
- Because of the pain I am unable to do any washing and dressing without help.
Sleeping*
- Does Not Apply
- I get no pain in bed.
- I get pain in bed but it does not prevent me from sleeping well.
- Because of pain my normal sleep is reduced by less than 25%.
- Because of pain my normal sleep is reduced by less than 50%.
- Because of pain my normal sleep is reduced by less than 75%.
- Pain prevents me from sleeping at all.
Lifting*
- Does Not Apply
- I can lift heavy weights without extra pain.
- I can lift heavy weights but it causes extra pain.
- Pain prevents me from lifting heavy weights off the floor.
- 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 off the floor, but I can manage light to medium weights if they are conveniently positioned.
- I can only lift very light weights.
Sitting*
- Does Not Apply
- I can sit in any chair as long as I like.
- I can only sit in my favorite chair as long as I like.
- Pain prevents me from sitting more than 1 hour.
- Pain prevents me from sitting more than 1/2 hour.
- Pain prevents me from sitting more than 10 minutes.
- I avoid sitting because it increases pain immediately.
Traveling*
- Does Not Apply
- I get no pain while traveling.
- I get some pain while traveling but none of my usual forms of travel make it worse.
- I get extra pain while traveling but it does not cause me to seek alternate forms of travel.
- I get extra pain while traveling which causes me to seek alternate forms of travel.
- Pain restricts all forms of travel except that done while lying down.
- Pain restricts all forms of travel.
Standing*
- Does Not Apply
- I can stand as long as I want without pain.
- I have some pain while standing but it does not increase with time.
- I cannot stand for longer than 1 hour without increasing pain.
- I cannot stand for longer than 1/2 hour without increasing pain.
- I cannot stand for longer than 10 minutes without increasing pain.
- I avoid standing because it increases pain immediately.
Social Life*
- Does Not Apply
- My social life is normal and gives me no extra pain.
- My social life is normal but increases the degree of pain.
- Pain has no significant affect on my social life apart from limiting my more energetic interests (e.g., dancing, etc).
- Pain has restricted my social life and I do not go out very often.
- Pain has restricted my social life to my home.
- I have hardly any social life because of the pain.
Walking*
- Does Not Apply
- I have no pain while walking.
- I have some pain while walking but it doesn’t increase with distance.
- I cannot walk more than 1 mile without increasing pain.
- I cannot walk more than 1/2 mile without increasing pain.
- I cannot walk more than 1/4 mile without increasing pain.
- I cannot walk at all without increasing pain.
Changing Degree of Pain*
- Does Not Apply
- My pain is rapidly getting better.
- My pain fluctuates but overall is definitely getting better.
- My pain seems to be getting better but improvement is slow.
- My pain is neither getting better or worse.
- My pain is gradually worsening.
- My pain is rapidly worsening.
Pain Intensity Number
Personal Care Number
Sleeping Number
Lifting Number
Sitting Number
Traveling Number
Standing Number
Social Life Number
Walking Number
Changing Degree of Pain Number
Back Index Number
Index Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things*
- Not at all
- Several Days
- More than half days
- Nearly every day
Feeling down, depressed or hopeless*
- Not at all
- Several Days
- More than half days
- Nearly every day
PHQ 2 Score

DASH

Please rate your ability to do the following activities in the last week by checking the number beside the appropriate response.
Name*
First Last
Your Physical Therapist*
- Dr. Paul Ochoa
- Dr. Monique Dupree
- Dr. Nick Langelotti
Your Date of Birth*
1. Open a tight or new jar.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 1
2. Write.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 2
3. Turn a key.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 3
4. Prepare a meal.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 4
5. Push open a heavy door.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 5
6. Place an object on a shelf above your head.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 6
7. Do heavy household chores (e.g., wash walls, wash floors).*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 7
8. Garden or do yard work.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 8
9. Make a bed.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 9
10. Carry a shopping bag or briefcase.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 10
11. Carry a heavy object (over 10 lbs).*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 11
12. Change a lightbulb overhead.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 12
13. Wash or blow dry your hair.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 13
14. Wash your back.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 14
15. Put on a pullover sweater.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 15
16. Use a knife to cut food.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 16
17. Recreational activities which require little effort (e.g., cardplaying, knitting, etc.).*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 17
18. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 18
19. Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.).*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 19
20. Manage transportation needs (getting from one place to another).*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 20
21. Sexual activities.*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- Unable
- Does Not Apply
Number 21
22. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours or groups? (circle number)*
- Not At All
- Slightly
- Moderately
- Quite A Bit
- Extremely
- Does Not Apply
Number 22
23. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem?*
- Not Limited At All
- Slightly Limited
- Moderately Limited
- Very Limited
- Unable
- Does Not Apply
Number 23
Please rate the severity of the following 5 symptoms in the last week.
(# 24 thru # 28 )
24. Arm, shoulder or hand pain.*
- None
- Mild
- Moderate
- Severe
- Extreme
- Does Not Apply
Number 24
25. Arm, shoulder or hand pain when you performed any specific activity.*
- None
- Mild
- Moderate
- Severe
- Extreme
- Does Not Apply
Number 25
26. Tingling (pins and needles) in your arm, shoulder or hand.*
- None
- Mild
- Moderate
- Severe
- Extreme
- Does Not Apply
Number 26
27. Weakness in your arm, shoulder or hand.*
- None
- Mild
- Moderate
- Severe
- Extreme
- Does Not Apply
Number 27
28. Stiffness in your arm, shoulder or hand.*
- None
- Mild
- Moderate
- Severe
- Extreme
- Does Not Apply
Number 28
29. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?*
- No Difficulty
- Mild Difficulty
- Moderate Difficulty
- Severe Difficulty
- So Much Difficulty That I Can't Sleep
- Does Not Apply
Number 29
30. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem.*
- Strongly Disagree
- Disagree
- Neither Agree Or Disagree
- Agree
- Strongly Agree
- Does Not Apply
Number 30
DASH Score
( [(sum of n responses / n) - 1] x 25, where n is the number of completed responses.)
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things*
- Not at all
- Several Days
- More than half days
- Nearly every day
Feeling down, depressed or hopeless*
- Not at all
- Several Days
- More than half days
- Nearly every day
PHQ 2 Score

LEFS

We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity.

Today, do you or would you have any difficulty at all with:
Name*
First Last
Your Physical Therapist*
- Dr. Paul Ochoa
- Dr. Monique Dupree
- Dr. Nick Langelotti
Your Date of Birth*
Any of your usual work, housework, or school activities.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Your usual hobbies, recreational or sporting activities.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Getting into or out of the bath.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Walking between rooms.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Putting on your shoes or socks.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Squatting.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Lifting an object, like a bag of groceries from the floor.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Performing light activities around your home.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Performing heavy activities around your home.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Getting into or out of a car.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Walking 2 blocks.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Walking a mile.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Going up or down 10 stairs (about 1 flight of stairs).*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Standing for 1 hour.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Sitting for 1 hour.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Running on even ground.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Running on uneven ground.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Making sharp turns while running fast.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Hopping.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
Rolling over in bed.*
- Extreme Difficulty or Unable to Perform Activity
- Quite a Bit of Difficulty
- Moderate Difficulty
- A Little Bit of Difficulty
- No Difficulty
LEFS Number
SCORE: _____/ 80
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things*
- Not at all
- Several Days
- More than half days
- Nearly every day
Feeling down, depressed or hopeless*
- Not at all
- Several Days
- More than half days
- Nearly every day
PHQ 2 Score

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Neck Index

Back Index

DASH

LEFS

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