This questionnaire is designed to give us information as to how your neck pain affects your ability to manage in everyday life.

Please answer every section and make sure to choose the one option that most closely describes you today.


Required fields are marked with an asterisk *.
Pain Intensity
Personal Care (Washing, Dressing etc.)
Lifting
Before getting out of bed, it is essential to
The first time you are expected to get up out of bed with the physical therapist is
Reading
Headaches
Concentration
Work
Driving
Sleeping
Recreation
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