PATMOS Cervical Thoracic

Walking

Symptoms do not prevent me walking any distance

Symptoms prevent me walking more than 1 mile.

Symptoms prevent me walking more than 1/2 mile.

Symptoms prevent me walking more than 1/4 mile.

i can only walk using a stick or crutches.

i am in bed most of the time and have to crawl to the toilet.

Concentration

I can concentrate fully when i want to with no difficulty.

I have a fair degree of difficulty in concentrating when i want to.

I have a lot of difficulty in concentrating when i want to.

I have a great deal of difficulty in concentrating when i want to.

I cannot concentrate at all.

Work
(Applies to work in home and outside)

I can do as much work as i want to.

I can only do my usual work, but no more.

I can do most of my usual work, but no more.

I cannot do my usual work.

i can hardly do any work at all (only light duty).

I cannot do any work at all.

Headaches

I have no headaches at all.

I have slight headaches which come less than 3 per week

I have moderate headaches which come infrequently.

I have moderate headaches which come 4 or more per week.

I have severe headaches which come frequently.

Sleeping

I have no trouble sleeping.

My sleep is mildly disturbed (less than 1 hr. sleepless).

My sleep is mildly disturbed (1–2 hrs. sleepless).

My sleep is moderately disturbed (2–3 hrs. sleepless).

My sleep is greatly disturbed (3–5 hrs. sleepless).

My sleep is completely disturbed (5–7 hrs. sleepless).

Driving

i can drive my car or travel without any extra symptoms.

i can drive my car or travel as long as i want with slight symptoms.

i can drive my car or travel as long as i want with moderate symptoms.

i cannot drive my car or travel as long as i want because of moderate symptoms.

i can hardly drive at all or travel because of severe symptoms.

i cannot drive my car or travel at all.

Recreation / Sports

(Indicate Sport if Appropriate)

i am able to engage in all my recreational/sports activities without increased symptoms.

i am able to engage in all my recreational/sports activities with some increased symptoms.

i am able to engage in most, but not all of my usual recreational/ sports activities because of increased symptoms.

i am able to engage in a few of my usual recreational/sports activities because of my increased symptoms.

i can hardly do any recreational/sports activities because of increased symptoms.

i cannot do any recreational/sports activities at all.

Lifting

i can lift heavy weights without extra symptoms.

i can lift heavy weights, but it gives extra symptoms.

My symptoms prevent me from lifting heavy weights, but i manage if they are conveniently positioned (e.g. on a table).

My symptoms prevent me from lifting heavy weights, but i manage light to medium weights if they are conveniently positioned.

i can lift only very light weights.

i cannot lift or carry anything at all

How many days ago did onset/injury occur?

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)

No lost work time

Return to work without restriction

Return to work with modification

Have not returned to work

Not employed outside the home

Work days lost due to condition:

Messages

Tasks

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

GLOBAL RATING OF CHANGE

Very Much Worse

Unchanged

Completely Recovered

WORKSTATUS

Messages

Tasks

Cervical / Thoracic

Functional IndexChoose 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

GLOBAL RATING OF CHANGE

Very Much Worse

Unchanged

Completely Recovered

WORKSTATUS

Functional Index
Choose the one answer in each section that best describes your condition.

Work
(Applies to work in home and outside)