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 below

GLOBAL 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
-7
-6
-5
-4
-3
-2
-1
0
1
2
3
4
5
6
7

WORKSTATUS


(check most appropriate)
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