STANDARD SPINAL ASSESSMENT FORM This document contains a series of standard assessments that are very useful in helping

us assess your spinal problem. The questions also help to determine whether or not there has been any benefit from the treatments you have received.
I.D. Label: NAME Date of Birth
TODAYS DATE:

POST SURGICAL ONLY:

Please circle

Compared to before your surgery are you

Much better

Better

The same

Worse

Please grade how you view your surgical treatment Please circle

Excellent

Good

Fair

Poor

THIS IS FOR EVERYONE PLEASE. ANSWER BY CIRCLING THE WORDS THAT BEST FIT YOUR PROBLEM.
Which pain is the worse pain?

BACK PAIN YES 7-12 weeks

LEG PAIN NO More than 12 weeks

Does the leg pain go below the knee? How long have you had your present pain? Less than 7 weeks

How far can you walk before you have to stop? 100 yards 200 yards 400 yards 800 yards 1 mile or more

What is your current status? E.g. Student, housewife, working, retired, disabled How much time have you lost from work in the last year?
Please circle None

Less than a week Six to twelve weeks More than one year YES YES YES

between one and three weeks three to six months

three to six weeks six to twelve months Are you receiving disability Benefit?

NO NO NO

Is there any personal injury claim pending regarding your back pain? Have you had to retire because of your back?

Please mark on the line below how much pain you have had from your leg, on average, over the past week.

10

No pain at all.

Maximum pain possible.

Please mark on the line below how much pain you have had from your back, on average, over the past week.

10

No pain at all.

Maximum pain possible.

THE OSWESTRY DISABILITY INDEX FOR LOW BACK PAIN

Please read: This section has been designed to give the doctor information as to how your back pain has affected your ability to manage in every-day life. Please answer every section and mark in each section only ONE statement which applies to you. We realise you may consider that two of the statements in any one section relate to you but please just tick the statement which most closely describes your problem. SECTION 1 - PAIN INTENSITY [] [] [] [] [] []
I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment The pain is very severe at the moment. The pain is the worst imaginable at the moment.

SECTION 2 - PERSONAL CARE (Washing, dressing etc.) [] [] [] [] [] [] I can look after myself normally without causing extra pain. I can look after myself normally but it is very painful. It is painful to look after myself and I am slow and careful. I need some help but manage most of my personal care. I need help every day in most aspects of self care. I do get dressed; wash with difficulty; and stay in bed.

SECTION 3 LIFTING [] [] [] [] [] [] I can lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned e.g. on a table. Pain prevents me from lifting heavy weights but I can 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.

SECTION 4 WALKING [] [] [] [] [] [] Pain does not prevent me walking any distance Pain prevents me walking more than 1 mile. Pain prevents me walking more than a quarter of a mile. Pain prevents me walking more than 100 yards. I can only walk if I use a stick or crutches. I am in bed most of the time and have to crawl to the toilet.

IT IS IMPORTANT TO ANSWER EACH SECTION

SECTION 5 SITTING [] [] [] [] [] [] I can sit in any chair as long as I like. I can sit in my favourite chair as long as I like. Pain prevents me from sitting more than 1 hour. Pain prevents me from sitting more than half an hour. Pain prevents me from sitting more than 10 minutes. Pain prevents me from sitting at all.

SECTION 6 STANDING [] [] [] [] [] [] I can stand as long as I want without extra pain. I can stand as long as I want, but it gives me extra pain. Pain prevents me from standing for more than 1 hour. Pain prevents me from standing for more than half an hour. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing at all.

SECTION 7 SLEEP [] [] [] [] [] []
My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours sleep. Because of pain I have less than 4 hours sleep. Because of pain I have less than 2 hours sleep.

Pain prevents me from sleeping at all.

SECTION 8 - SEX LIFE [] [] [] [] [] [] My sex life is normal and causes no extra pain. My sex life is normal but causes some extra pain. My sex life is nearly normal but is very painful. My sex life is severely restricted by pain. My sex life is nearly absent because of pain. Pain prevents any sex life at all.

SECTION 9 - SOCIAL LIFE [] [] [] [] [] [] My social life is normal and causes me no extra pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g.. sport, etc Pain has restricted my social life and I do not go out as often. Pain has restricted my social life to my home. I have no social life because of pain.

SECTION 10 TRAVELLING [] [] [] [] [] [] I can travel anywhere without pain. I can travel anywhere but it gives extra pain. Pain is bad but I manage journeys over 2 hours. Pain restricts me to journeys of less than 1 hour. Pain restricts me to short necessary journeys under 30 minutes. Pain prevents me travelling except to receive treatment.

IT IS IMPORTANT TO ANSWER EACH SECTION

PAIN DRAWING
MARK THE AREA ON YOUR BODY WHERE YOU FEEL THE DESCRIBED SENSATIONS. USE THE APPROPRIATE SYMBOL. MARK THE AREAS OF RADIATION. INCLUDE ALL AFFECTED AREAS AS BEST YOU CAN.

Numbness ======

Pins and Needles

Burning xxxxx

Stabbing //////

BACK FUNCTIONAL ASSESSMENT

Please tick the answer which most closely describes you in each of the following six sections: 1) Do you have to rest during the day because of pain? Not at all. A little. Half the day. Over half the day. [ [ [ [ ] ] ] ]

2) How often do you have a consultation with a Never. doctor or have any treatment (e.g. physiotherapy) Rarely. for your pain? About once a month. More than once a month.

[ [ [ [

] ] ] ]

3) How often do you have to take pain-killers for your pain?

Never. Occasionally. Almost every day. Several times each day.

[ [ [ [

] ] ] ]

4) At present are you working?

Full time at your usual job. Full time at a lighter job. Part time. Not working.

[ [ [ [

] ] ] ]

5) At present can you undertaking sports or active pursuits (e.g. dancing)?

As much as usual. Almost as much as usual. Some, much less than usual. Not at all.

[ [ [ [

] ] ] ]

6) At present can you undertake household chores or odd jobs?

Normally. [ ] As much as before but slowly. [ ] A few - not as many as usual. [ ] Not at all. [ ]

Please mark on the line below how much pain you have had from your back, on average, over the past week.

10

No pain at all.

Maximum pain possible.

Please tick the box that describes best how much your back pain affects each of the following six activities: No effect. Sex life. Sleeping. Walking. Sitting. Travelling. Dressing. [ ] [ ] [ ] [ ] [ ] [ ] Mildly/not much. [ ] [ ] [ ] [ ] [ ] [ ] Moderate/difficult. [ ] [ ] [ ] [ ] [ ] [ ] Severely / impossible. [ ] [ ] [ ] [ ] [ ] [ ]

PLEASE DESCRIBE HOW YOU HAVE FELT DURING THE PAST WEEK BY MAKING A TICK IN THE APPROPRIATE BOX. PLEASE ANSWER ALL QUESTIONS. ANSWER. DO NOT THINK TOO LONG BEFORE YOU Not at all. Heart rate increase. Feeling hot all over. Sweating all over. Sweating in a particular part of the body. Pulse in neck. Pounding in head. Dizziness. Blurring of vision. Feeling faint. Everything appearing unreal. Nausea. Butterflies in stomach. Pain or ache in stomach. Stomach churning. Desire to pass water. Mouth becoming dry. Difficulty swallowing. Muscles in neck aching. Legs feeling weak. Muscles twitching or jumping. Tense feeling across forehead. Tense feeling in jaw muscles. MSP A little, A great deal, Extremely. slightly. quite a lot. Could not be worse.

PLEASE INDICATE FOR EACH OF THESE QUESTIONS WHICH ANSWER BEST DESCRIBES HOW YOU HAVE BEEN FEELING RECENTLY.

Rarely or none. (Less than 1 day per week)

Some or little. (1-2 days per week)

Moderate amount (3-4 days per week)

Most of time. (5-7 days per week)

I feel downhearted and sad. Morning is when I feel best. I have crying spells or feel like it. I have trouble getting to sleep at night. I feel that nobody cares. I eat as much as I used to. I still enjoy sex. I notice I am losing weight. I have trouble with constipation. My heart beats faster than usual. I get tired for no reason. My mind is as clear as it used to be. I tend to wake up too early. I find it easy to do the things I used to. I am restless and cant keep still. I feel hopeful about the future. I am more irritable than usual. I find it easy to make a decision. I feel quite guilty. I feel that I am useful and needed. My life is pretty full. I feel that others would be better off if I were dead. I am still able to enjoy the things I used to.
MZDI