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.SELECTBACK INDEXNECK INDEXDASHLEFS 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 Your Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pain 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 NumberPersonal Care Hidden NumberSleeping Hidden NumberLifting Hidden NumberReading Hidden NumberDriving Hidden NumberConcentration Hidden NumberRecreation Hidden NumberWork Hidden NumberHeadaches Hidden NumberNeck Index TotalIndex Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100Over 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 HiddenPHQ 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pain 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 NumberPersonal Care NumberSleeping NumberLifting NumberSitting NumberTraveling NumberStanding NumberSocial Life NumberWalking NumberChanging Degree of Pain NumberBack Index NumberIndex Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100Over 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 HiddenPHQ 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201. Open a tight or new jar.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 12. Write.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 23. Turn a key.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 34. Prepare a meal.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 45. Push open a heavy door.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 56. Place an object on a shelf above your head.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 67. Do heavy household chores (e.g., wash walls, wash floors).* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 78. Garden or do yard work.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 89. Make a bed.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 910. Carry a shopping bag or briefcase.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1011. Carry a heavy object (over 10 lbs).* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1112. Change a lightbulb overhead.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1213. Wash or blow dry your hair.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1314. Wash your back.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1415. Put on a pullover sweater.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1516. Use a knife to cut food.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1617. Recreational activities which require little effort (e.g., cardplaying, knitting, etc.).* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 1718. 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 1819. 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 1920. Manage transportation needs (getting from one place to another).* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 2021. Sexual activities.* No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Does Not Apply Number 2122. 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 2223. 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 23Please 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 2425. Arm, shoulder or hand pain when you performed any specific activity.* None Mild Moderate Severe Extreme Does Not Apply Number 2526. Tingling (pins and needles) in your arm, shoulder or hand.* None Mild Moderate Severe Extreme Does Not Apply Number 2627. Weakness in your arm, shoulder or hand.* None Mild Moderate Severe Extreme Does Not Apply Number 2728. Stiffness in your arm, shoulder or hand.* None Mild Moderate Severe Extreme Does Not Apply Number 2829. 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 2930. 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 30DASH 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 HiddenPHQ 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Any 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 NumberSCORE: _____/ 80Over 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 HiddenPHQ 2 Score
