eKonsey

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Patient Information

Full Name *

Age *

Location of pain:

Pain Location:

Center

Right

Left

Is there a region where it spreads?

Does the pain spread to any other areas?

Left side of the back

Right side of the back

Left shoulder

Right shoulder

Between left shoulder and elbow

Between right shoulder and elbow

Below left elbow, down to hands

Below right elbow, down to hands

In every area, throughout the left arm

In every area, throughout the right arm

Other Information

Are there any other symptoms apart from the pain?

Are your neck movements restricted?

Yes

Do feel restricted or experience pain while moving your shoulders?

Yes

Have you experienced balance issues, falling etc.?

Yes

When did your symptoms start?

How long do you suffer the symptoms in a day/every day?

Does the pain wake you up at night?

Yes

Are your bladder and bowel functions normal?

Yes

Do you have any other diseases?

Have you had a car accident effecting your neck, or experienced a neck trauma?

Have you received any treatments for this symptom?

Neck Disability Index (NDI)

Intensity of neck pain

I do not have a neck pain now.

I have a mild neck pain now.

I have a moderate and occasional neck pain.

I have a moderate and constant neck pain now.

I have a very severe pain now but it comes and goes occasionally.

I have a severe and constant neck pain now.

Personal care (getting dressed and washing)

I can look after myself normally without causing extra pain.

I can look after myself normally but it causes extra pain.

My pain increases while I am looking after myself, so I move slowly and carefully.

I need some help but I can manage most of my personal care.

I need help every day in most aspects of my self-care.

I can't get dressed. I wash with difficulty and I stay in bed.

Lifting weights (equal to the heavy weights you lift when you do not have a neck pain)

I can lift heavy weights without causing extra pain.

I can lift heavy weights but it causes extra pain.

Pain prevents me from lifting heavy weights off the floor but I can lift them if they are properly positioned on higher places such as a table.

Pain prevents me from lifting heavy weights but I can lift light to medium objects if they are properly positioned on places such as a table.

I can lift very light objects.

I can't lift or carry anything at all.

Reading

I can read as long as I like without feeling extra neck pain.

I can read as long as I want but it causes a mild neck pain.

I can read as long as I want but it causes a moderate neck pain.

Because of the moderate neck pain I can't read as long as I like.

Because of the severe neck pain I can't read as long as I like.

Because of my neck pain I can't read at all.

Headaches

I have no headache.

I have mild headaches which are not very often.

I have moderate headaches.

I often have modearate headaches.

I often have severe headaches.

I almost always have a headache.

Concentration

I can concentrate on things as long as I like without difficulty when I want to.

I can focus with a little difficulty.

I can focus with a little difficulty when I want to.

I can focus with great difficulty when I intend to.

I can focus with really great difficulty when intend to.

I am unable to concentrate at all.

Job (If you do not work please mark the option G)

I can do as much chores as I like.

I can do my daily chores, but nothing more.

I can do most of my daily chores, but nothing more.

I can't do my daily chores.

I can do anything but with difficulty.

I can't do anything at all.

Driving

I can drive without feeling neck pain.

I can drive but I feel a mild neck pain.

Because of the moderate pain in my neck I can't drive as much as I like.

Because of the moderate neck pain I can't drive as much as I like.

Because of the severe neck pain I can drive with difficulty.

Because of the neck pain I can't drive at all.

Sleep

I have no trouble sleeping.

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

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

My sleep is moserately disturbed (2-3hrs. sleepless).

My sleep is severely disturbed (3-5 hrs. sleepless).

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

Spare time activities

I can do all the spare time activities with no neck pain at all.

I can do all the spare time activities with some neck pain.

I can do some of the spare time activities because of the pain in my neck.

I can do very few of the spare time activities because of the pain in my neck.

I can hardly do spare time activities because of the pain in my neck.

I can't do any spare time activities at all.

Inspections

No diagnostic procedures

X-ray

Complete MRI scan of the Abdomen

Complete CT scan of the Abdomen

EMG

Other

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Neck Pain

Neck Pain

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Patient Information

Location of pain:

Is there a region where it spreads?

Other Information

Neck Disability Index (NDI)

Inspections

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