Patient Questionnaire

Hartley Chiropractic and Scoliosis Center Patient Questionnaire

This form helps us assess the condition and impact of your scoliosis. It is IMPORTANT THAT YOU ANSWER EACH OF THESE QUESTIONS YOURSELF.

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Which one of the following best describes the amount of pain you have experienced during the past 6 months?

Which one of the following best describes the amount of pain you have experienced over the last month?

During the past 6 months have you been a very nervous person?

If you had to spend the rest of your life with your back shape as it is right now, how would you feel about it?

What is your current level of activity?

How do you look in clothes?

In the past 6 months have you felt so down in the dumps that nothing could cheer you up?

Do you experience back pain when at rest?

What is your current level of work/school activity?

Which of the following best describes the appearance of your trunk; defined as the human body except for the head and extremities?

Which one of the following best describes your pain medication use for back pain?

Does your back limit your ability to do things around the house?

Have you felt calm and peaceful during the past 6 months?

Do you feel that your back condition affects your personal relationships?

Are you and/or your family experiencing financial difficulties because of your back?

In the past 6 months have you felt down hearted and blue?

In the last 3 months have you taken any days off of work, including household work, or school because of back pain?

Does your back condition limit your going out with friends/family?

Do you feel attractive with your current back condition?

Have you been a happy person during the past 6 months?

Are you satisfied with the results of your back management?

Would you have the same management again if you had the same condition?