Home Contents Street Map Address

Patient Outcome Form

Home Up

 

Members of the Adelaide Spine Clinic are always looking for ways to increase our knowledge and understanding of spinal complaints.  To assist in this process individuals who undergo surgical intervention,  and in some cases individuals who take part in other non operative treatment programs, will be asked to complete a "Patient Outcome Form". 

The information collected in this way helps us to evaluate the results of treatment and to assess the best way to treat specific spinal complaints and conditions.

Patient Outcome Form

1    Please indicate by a mark on the line below how much pain you have had in your neck or back on average during the past week.

     
 0            1            2           3            4            5            6            7            8           9           10
No Pain                                                                                                                        Worst Pain

2    Do you have to rest during the day because of your pain?



     No  Half the day



     A little  Over half the day

3    How often have you seen a doctor or had treatment (eg physiotherapy) for your pain?



     Never  About once a month



     Rarely  More than once a month

4    At present, are you working?     (housewives relate activity to previous abilities)



     Full time at your usual job  Part time



     Full time a a lighter job  Not working

      Date returned to work?         /        /            

5    At present, can you undertake sports or active pursuits? (eg dancing)



     As much as usual  Some, much less than usual



     Almost as much as usual  Not at all

6    At present, can you undertake household chores or odd jobs?



     Normally  Not as many as usual



     As much as usual but slowly  Not at all

7    Mark the box that describes best how much your back/neck pain affects each of the following activities

No Effect Mildly / 
Not Much		 Moderately / Difficult Severely / Impossible
Sleeping    
Walking    
Sitting    
Travelling    
Dressing    
Sex Life    
Working    
Sports    
Exercise    

 

8    How often do you have to take pain killers for your pain?



     Never  Almost every day



     Occasionally  Several times each day

9    Choose the activity level from the list below that best represents your functional capacity

 Bedridden  Restricted medium duties
 Wheelchair  Medium duties
 Housebound  Heavy work with pain
 Light physical activity  No limitation
 Light duties

10 

CAN YOU

YES

NO

Lift a small (3 year old) child?

  

Sit for half an hour?

  

Stand in one place for half an hour?

  

Travel in a car or bus for half an hour?

  

Walk 500 metres?

  

Put on footwear, tights, socks etc without help?

  

Vacuum, do washing, shopping, mow lawns and
    do general home maintenance without help?

  

DOES YOUR BACK/NECK PAIN

YES

NO

Disturb your sleep regularly? (2-3 times per week)

  

Curtail your social activities?

  

Reduce your frequency of sexual activity?

  

 11  Indicate in RED the areas on your body where you feel pain.  Shade in BLUE the areas on your body where you feel numbness, tingling or pins & needles.

 

12  Do you consider your operation or treatment a success?

 Yes  No

13  Would you undergo the same operation or treatment again?

 Yes  No
 

 

Send mail to spine@adelaide.on.net  with questions or comments about this web site.
Last modified: February 18, 2002