Cervical / Thoracic
Functional Index
Choose the one answer in each section that best describes your
condition.
Walking
Concentration
Work
(Applies to work in home and outside)
Headaches
Sleeping
Driving
Recreation / Sports
Lifting
Pain Index
Please indicate the worst your pain has been in the last 24 hours on the scale belowGLOBAL RATING OF CHANGE
With respect to the reason you sought treatment, how would you describe yourself now compared to your first treatment at our clinic?
Very Much Worse
Unchanged
Completely Recovered
WORKSTATUS
(check most appropriate)