Patient Information
(PLEASE PRINT LEGIBLY)
Today’s Date:________________________________________________________________________
Last Name:___________________________________ First Name: _________________ MI: _______
Mailing Address: ____________________________________________________________________
City_______________________________ State________________________ ZIP_________________
Home Phone:____________________ Cell Phone:_________________ Work Phone_______________
Email Address:_______________________________________________________________________
DOB:___________________________ Age: _________________________ Sex: _________________
Natural Child
 Step Child
Foster Child
Grand Child
Niece/Nephew Ward of the Court
Handicapped Dependent
Single
Married
Widowed
Separated
Divorced
Patient Social Security Number_______________________________ Student
 YesNo
Patients Employer_______________________________________________  Full Time  Part Time
Occupation _______________________Employer Address____________________________________
City___________________________ State______________Zip_________ Phone_________________
Primary Physician_____________________________________________________________________
Referring Physician____________________________________________________________________
Diagnosis________________________________ Date of Injury/Onset___________________________
Spouse/Guardian/Parent Name____________________________________ Relationship____________
DOB________________ Social Security Number______________________ Phone________________
Mailing Address______________________________City_______________State_______Zip________
Employer__________________________________ Occupation________________________________
Emergency Contact Name:___________________________ Phone:_____________________________
INSURANCE
Who is responsible for this account?_________________ Relationship to Patient___________________
Primary Insurance___________________________________________________________________
Address__________________________City______________State_____________Zip______________
ID/Case#___________________________________________ Group#__________________________
Insured Name_______________________DOB________________SSN#________________________
Secondary Insurance__________________________________________________________________
Address__________________________City______________State_____________Zip______________
ID/Case#___________________________________________ Group#__________________________
Are you or could you be pregnant?  YesNo
YesNo How often?____________________
Are you allergic to:
Adhesive tape
 YesNo
Any medication
 YesNo
If “YES”: please list:___________________________________________________________________
Please list surgical procedures:___________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Other pertinent information:_____________________________________________________________
YOUR Medical History
Please indicate if YOU have a history of the following:
Alcohol Abuse
Transmitted Disease
-Johnson Syndrome
of the Hand/Feet/Ankles
Cancer
/Significant Medical Illness
Diabetic
FAMILY Medical History
Please indicate if YOUR FAMILY has a history of the following:
(ONLY include parents, grandparents, siblings, and children)
er
-Johnson Syndrome
e
MEDICARE ONE TIME AUTHORIZATION:
I_________________________________, request that payment of authorized Medicare benefits made
to me on my behalf for any services, physical therapy or softgoods, furnished to me by Big Country
Rehab. I authorize any holder of medical information about me to release to the Health Care Financing
Administration and its agents any information needed to determine these benefits or benefits payable for
related services. If “other health insurance” is indicated in item 9 of the HCFA-1500 in the form of, or
elsewhere on other approved claim forms or electronically submitted claims, my signature authorized
release of the information to the insurer or agency shown. In Medicare assigned cases, Big Country
Rehab agrees to accept the charge determination of the Medicare carrier as the full coverage. The patient
is responsible only for the deductible, coinsurance, and noncovered services. Coinsurance and the
deductible are based upon the character determination of the Medicare carrier.
_____________________________________________________________________________
Beneficiary Signature
Date
ASSIGNMENT AND RELEASE
I, the undersigned certify that my dependent or I have insurance coverage with, ______________
_______________________________________________________________________________
And assign directly to Big Country Rehab all insurance benefits, if any, otherwise payable to me for
services rendered. I understand that I am financially responsible for all charges whether or not paid by
insurance. I hereby authorize that Big Country Rehab can release all information necessary to secure the
payment of benefits. I further authorize Big Country Rehab to contact the Insurance Commissioner on
my behalf in the event of insurance problems. I authorize the use of this signature on all insurance
submissions.
____________________________________
Responsible Party Signature
________________________________________________________________________________
Relationship
Date
-I HAVE READ THE ABOVE AND I AGREE TO THE TERMS.
-I HEREBY ACKNOWLEDGE RECEIPT OF A COPY OF THIS FORM.
-I HEREBY AUTHORIZE BIG COUNTRY REHAB TO PERFORM SUCH TREATMENTS AND
PROCEDURES THE PHYSICIAN HAS ORDERED FOR TREATMENT.
-I UNDERSTAND THAT BIG COUNTRY REHAB WILL HOLD ALL MY INFORMATION
REGARDING MY CONDITION CONFIDENTIAL.
-I HEREBY GIVE PERMISSION TO RELEASE NECESSARY INFORMATION TO MY
INSURANCE COMPANY, ATTORNEY, MEDICAL DOCTOR, MEDICARE, MEDICAID OR
WORKERS COMPENSATION.
___________________________________________________________________________
Name of Patient (Print)
& Signature of RESPONSIBLE PARTY
HIPPA NOTICE OF PRIVACY PRACTICES
North Platte Physical Therapy
Effective Date:
April 14, 2003
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CAREFULLY
WHO WILL FOLLOW THIS NOTICE (including affiliates):
North Platte Physical Therapy; Big Country Rehabilitation
OUR PLEDGE REGARDING HEALTH INFORMATION:
We are required by law to make sure that health information that identifies you is kept private; to give you this notice of our
legal duties/privacy practices with respect to health information about you; and to follow the term of the notice that is
currently in effect.
HOW WE HAVE USED AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose health information. Not every use of disclosure in a
category will be listed. However, all of the ways are permitted to use and disclose information will fall within one of the
categories.
For Treatment: We may use health information about you to provide you with health care treatment or services. We may
disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in
taking care of you. They may work at our offices, at a doctor’s office or other health care providers to whom we may refer
you. For example, we may contact your physician’s office and speak with a nurse regarding any concern we may have about
unusual swelling associated with your ankle rehabilitation.
For Payment: We may use and disclose health information about you so that the treatment and services you receive from us
may be billed to and payment collected from you, and insurance company, or a third party. For example, we may need to give
your health plan information about your visit so your health plan will pay us to reimburse you for your treatment.
For Health Care Operations: We may use and disclose health information about you for operations of our facility. These
uses and disclosures are necessary to run our practice and made sure that all of our patients receive quality care. For example,
we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for
you and documenting that care.
As Required By Law: We will disclose health information about you when required by federal, state, or local law.
Military or Veterans: If you are a member of the armed forces or separated/discharged from military services, we may
release health information about you as required by military command authorities of the Department of Veteran Affairs as
may be applicable.
Workers’ Compensation: We may release health information about you for Workers’ Compensation of other similar
programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks: We may disclose health information about you for public health activities. These activities generally
include but are not restricted to reporting reactions to medications or problems with products and notifying people of recalls
of products they may be using.
Health Oversight Activities: We may disclose health information about you to a health oversight agency for activities
authorized by law. These oversight activities include, for example, audits, investigations, and licensure.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in
response to a court or administrative order. We may also disclose health information about you in response to a court order,
subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been
made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement: We may release health information if asked to do so by a law enforcement official in response to a court
order, subpoena, warrant, summons, or similar process.
Coroners and Health Examiners: We may release health information to a coroner or health examiner.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release
health information about you to a correctional institution or law enforcement official.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU:
You have the following rights regarding health information we maintain about you.
Right to Inspect and Copy: You have the right to inspect and copy the protected health information that we maintain.
Usually this includes health and billing records. You must submit your request in writing to the Privacy Officer. If you
request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services
associated with your request. Your request will generally be approved unless there are legal or medical reasons to deny the
request. If you are denied access to health information, you may request that the denial by reviewed.
Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend
the information. You have the right to request an amendment for as long as we keep the information. To request an
amendment form please contact the Privacy Officer in writing and a form will be mailed to you. Completion of the form must
either be legibly handwritten or typed and returned to the Privacy Officer. You must provide a reason that supports your
request for an amendment. We may deny your request for an amendment if it is not in writing or does not include a reason to
support the request. In addition, we may deny your request if you ask us to amend information that:
 was not created by us, unless the person or entity that created the information is no longer available;
 is not part of the health information kept by us or for our practice;
 is not part of the information which you would be permitted to inspect and copy; or
 is accurate and complete.
Any amendment that we make to your health information will be disclosed to those with whom we disclose information as
previously specified.
Right to an Accounting Disclosure: You have the right to request a list of accounting for any disclosure or your health
information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously
described. To request this List of Disclosure, you must submit your request in writing to the Privacy Officer. Your request
must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first
list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the
list. We will not notify you of the cost involved and you may choose to withdraw or modify your request at that time before
any costs are incurred. We will mail you a list of disclosures within 30 days of your request.
Right to Request Restriction: You have the right to request a restriction of limitation on the health information we use or
disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health
information we disclose about you to someone who is involved in your care or the payment of your care, such as a family
member or friend. For example, you could ask that we not disclose information to your spouse about treatments. We are
required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will
negatively impact the care we may provide you.
IF we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To
request a restriction, you must make your request, in writing, to the Privacy Officer.
Right to Request Confidential Communications: You have the right to request that we communicate with you about health
matters in a certain way or at a certain location. For example, you can ask that we only contact you at home or by mail to a
post office box. To request confidential communications, you must make your request, in writing, to the Privacy Officer. We
will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or
where you wish to be contacted.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health
information we already have about you as well as any information we receive in the future. We will post a copy of the current
notice in our facility. This notice will contain, on the first page, in the top right corner, the effective date. In addition, each
time you register for treatment, we will offer you a copy of the current notice in effect if our records indicate you have not
been provided with the revised or changed notice.
COMPLAINTS:
If you believe your privacy rights have been violated, you may file a complaint with us. To file a complaint, contact the
Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Contact Information:
The name and address of the person you can contact for further information or to request any forms concerning our privacy
practices is:
Michelle Kern
620 4J Court, Ste. B
Gillette, WY 82716
307-686-2569
Effective Date: This notice is effective on or after April 14, 2003
Acknowledgment of Receipt of this Notice:
We will request that you sign a separate notice acknowledging you have received a copy of this notice. If you choose, or are
not able to sign, a staff member will sign their name and date that the notice was provided for you. This acknowledgement
will be filed with your records.
Please sign the following acknowledgement.
I, ____________________________________________________ received a copy of the Notice of Privacy
Practices from North Platte Physical Therapy or a designated affiliate on the _____ day of __________________.
This acknowledgement will be filed with your records.
Welcome! Thank you for selecting our office. It is our goal to provide your physical therapy needs as
thoroughly and efficiently as possible. To do that, we need to work with you as a team.
As part of the team you need to know and understand a few things. Before we begin we will discuss and
explain our treatment plan. Depending on your progress the plan may need to be changed. An estimate
of the total fee for your treatment is virtually impossible because we cannot tell how long it will take
you to progress. We will be able to tell you how much each treatment costs. If you are uncertain of any
change or cost feel free to ask. We are more than happy to answer your question. Your physician will
then be contacted for permission to treat a new diagnosis.
Our policy regarding payment for our professional services is as follows:
A:
Cash, Check or major credit card will be accepted at the time of treatment. Any account not paid
in full 90 days after treatment will bear interest at the rate of 1.5% per month or 18% annum.
B:
Treatment involving any laboratory work, braces, orthotics or prosthetic devices may require a
percentage of the total fee be paid before treatment begins or the device is ordered. This is necessary to
cover the laboratory fees or the cost of the device we must pay in advance.
C:
In the event we have to use an attorney to collect any unpaid balance due for services to you or
your family by signing the information form upon your first visit you agree to pay all costs of collection,
including all attorney fee whether suit is filed or not.
INSURANCE: As a courtesy to our patients we will file your primary insurance. Secondary insurance
submissions will be the responsibility of the patient. Please check your insurance policy prior to service
to be sure physical therapy is covered. We will file secondary for Medicare patients.
By Law we must file Medicare for you. Because we DO NOT accept assignment the payment and
explanation of benefits goes directly to you. We will file the secondary insurance if we are provided
with the information. Medicare rarely pays for supplies, but we will submit them just in case. The
amount not covered by Medicare and your secondary insurance will be your responsibility. Medicare
requires that patients see their physician every 30 days.
We will process Workers’ Compensation; however, you are required to let us know that you have a
workers’ compensation claim, and you must provide us with your case number, date of injury, social
security number and employers address. If we do not receive a case number from you, or if your claim is
denied you will be responsible for all charges incurred. If your case is under objection you will receive a
bill from us until your case is resolved.
If your insurance is Title 19 our office is required to collect a $2.45 co-pay per visit from anyone over
the age of 21. There is a 20 visit limit on patients over the age of 21. Please furnish your Equality card
monthly. Any visits over the 20 visit limit will be the patient’s responsibility for payment. Any one
under the age of 21, or who is Medicare/Medicaid, is not restricted by the above guidelines.
Please feel free to contact our office for questions or concerns regarding your treatment or the above
information.
_______________________________________________
Signature of Patient or Guardian if Patient is a Minor
____________________________
Date
PHYSICAL/OCCUPATIONAL THERAPY
Certain restrictions may apply with your insurance company for Physical Therapy and Occupational
Therapy services. We advise you to contact your insurance company by using the toll-free number on
the back of your insurance card to verify coverage. Some questions you may want to ask are:
1. Does my insurance cover Physical and/or Occupational Therapy Services?
2. If under treatment on a Workman’s Compensation claim, will Physical and/or Occupational
Therapy Services be covered? (These services must be authorized. If not, I understand I will
be responsible.) I understand if I do not attend my appointment and I do not cancel, my
employer will be notified.
3. Does Medicare Insurance cover Physical and/or Occupational Therapy Services? (I understand
that there are other approved providers of Medicare; for example, Blue Cross Blue Shield
WinHealth. However, some supplies such as: Exercise Bands, Electrodes and Iontophoresis
Patches are not covered by Medicare, and I am responsible for these purchases.)
4. Are there any restrictions on where I can receive these services?
5. My referring Physician may be an In Network Provider, is the Physical Therapy also an In
Network Provider?
6. Are there financial limitations on Physical Therapy services?
7. Do I need a pre-authorization number?
8. Does my insurance cover “iontophoresis and phonophoresis”? (You do need to ask this if you
will be receiving these treatments.)
9. Does my insurance cover miscellaneous supplies I may receive such as: braces, splints, exercise
band, ect…..?

If I cannot make an appointment, it is my responsibly to call and cancel. I understand that if I
do not call to cancel, I risk being removed from any further scheduled appointments that I’ve
made.

I have read the above questions and understand it is my responsibility to check my
insurance coverage.
(A copy of this form must be signed and will be place in the Patient’s File)
_______________________________________________
Signature of Patient or Guardian if Patient is a Minor
____________________________
Date
STANDING AUTHORIZATION FOR RELEASE OF
INFORMATION TO SPECIFIC PERSON(S)
NAME:______________________________ DOB:________________
ADDRESS:___________________________ SSN:_________________
____________________________ PHONE:______________
May we reach you or the below mentioned persons by phone?_______________
Let it be known to all persons associated with Big Country Rehabilitation, LLC that the
following individuals may be given information that I am on the premises. Let it also be known
that the following person(s) may receive information regarding my appointments, medical
conditions, insurance and billing information.
NAME:___________________________ RELATIONSHIP:________________________
NAME:___________________________ RELATIONSHIP:________________________
NAME:___________________________ RELATIONSHIP:________________________
ADDITIONAL NAMES LISTED ON BACK.
ACKNOWLEDGEMENT
I understand that any information disclosed by this authorization may be subject to received
disclosure by the recipient and will no longer be protected by HIPAA. The Facility and all
personnel covered under this entity are hereby released from any legal responsibility or liability
for disclosure of the above information to the extent indicated and authorized herein.
EXPIRATION
I understand that I may revoke this authorization by submitting a written notice to Big Country
Rehabilitation, LLC. This notice will remain in effect until such time it is revoked.
PATIENT SIGNATURE:________________________________ DATE:________________
REPRESENTATIVE’S SIGNATURE:______________________ DATE:_______________
RELATIONSHIP TO PATIENT IF NOT NAMED ABOVE:___________________________
PATIENT INSURANCE BENEFIT INFORMATION
PATIENT NAME
________________________________________________
ID:
________________________________________________
INSURANCE NAME
________________________________________________
PHONE NUMBER
________________________________________________
DOB
________________________________________________
CAL YEAR
MEDICARE:
There are two physical therapy caps. Each cap is $1960. However in order to use the second cap
appropriately there must be significant improvement shown. Softgoods are not a covered benefit (ie,
knee brace, orthotics, back brace.)
MEDICAID:
There is a $2.45 co-pay every visit as well as a 20 visit limit if you are over the age of 21. Softgoods are
not a covered benefit (ie, knee brace, orthotics, back brace.)
WORKER’S COMPENSATION:
You must be in contact with your caseworker. If there is new information please let us know.
CAR INSURANCE:
Stay in contact with your claims adjuster. If there is new information please let us know.
AUTHORIZATION AND/OR REFERRAL REQUIRED
YES – REFERRAL IS REQUIRED FOR ALL ABOVE INSURANCES.
IF IT IS WORKER’S COMPENSATION AUTHORIZATION IS REQUIRED.
We at Big Country Rehabilitation, LLC strive to help you with all your insurance questions or concerns.
As a reminder, any benefits quoted are not a guarantee of benefit. By signing this form, you are
responsible for all accrued charges during your treatment at Big Country Rehabilitation, LLC.
______________________________________________________________________________
Patient Signature
Date
______________________________________________________________________________
Office Staff Signature
Date
Date:
Patient Name:
Date of Injury
Where on your body?
Chief Complaint:
What happened?
How long has this been going on?
Where?
What goals would you
like to accomplish
with therapy?
How is your general
health?
Occupation:
Medical History
Cancer/Pacemaker/Seizures?
List anything you have been treated for:
Pain Rating
Worst: 0-1-2-3-4-5-6-7-8-9-10
Current: 0-1-2-3-4-5-6-7-8-9-10
Best: 0-1-2-3-4-5-6-7-8-9-10
Better with:
Worse with:
X-ray/MRI/Injections
List any diagnostic tests you have had:
Medications:
List your current medications and why:
FABQ
NAME:
DATE:
Here are some of the things which other patients have told us about their pain. For each statement please circle any number from 0
to 6 to say how much physical activity such as bending, lifting, walking, or driving affect or would affect your pain.
COMPLETELY
DISAGREE
1.
2.
3.
4.
My pain was caused by physical activity
Physical activity makes my pain worse
Physical activity might harm my back
I should not do physical activities which (might)
make my pain worse
5. I cannot do physical activities which
(might) make my pain worse
UNSURE
COMPLETELY
AGREE
0
0
0
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
The following statements are about how your normal work affects or would affect your pain.
COMPLETELY
DISAGREE
6. My pain was caused by my work or by an
accident at work
7. My work aggravated my pain
8. I have a claim for compensation for my pain
9. My work is too heavy for me
10. My work makes or would make my pain worse
11. My work might harm my back
12. I should not do my normal work with my present pain
13. I cannot do my normal work with my present pain
14. I cannot do my normal work until my pain is treated
15. I do not think that I will be back to my normal work
within 3 months
16. I do not think that I will ever be able to go
back to that work.
FABQ (1,8,13,14,16)
FABQPA:
/24
>/= 14 Cog/Be approach; >9 Poor Stab; Pos Tx Manip<12
FABQW:
UNSURE
COMPLETELY
AGREE
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
5
5
5
5
5
5
6
6
6
6
6
6
0
0
0
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
0
0
1
1
2
2
3
3
4
4
5
5
6
6
/42
Manip<19, Dis/CH>34, Low Dis/CH <29
References:
1.
2.
3.
Flynn T, Fritz J, Whitman J, Wainner R, et al. Clinical Prediction Rule for Classifying Patients with Low Back Pain Likely to Respond to a
Manipulation Technique. Spine (In Press) 2002.
Fritz JM, George SZ, Delitto A. The role of fear-avoidance beliefs in acute low back pain: relationships with a current and future disability
and work status. Pain 2001; 94:7-15.
Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance
beliefs in chronic low back pain and disability. Pain 1993; 52:157-168
NAME
DATE
LOWER EXTREMITY FUNCTIONAL SCALE
Please rate your ability to do the following activities in the last week by circling the number below the appropriate
response.
Activities
Any of your usual work, housework or school activities
Your usual hobbies, recreational or sporting activities
Getting into or out of the bath
Walking between rooms
Putting on your shoes and socks
Squatting
Lifting an object, like a bag of groceries from the floor
Performing light activities around your home
Performing heavy activities around your home
Getting into or out of a car
Walking 2 blocks
Walking 1 mile
Going up or down 10 stairs (about 1 flight of stairs)
Standing for 1 hour
Sitting for 1 hour
Running on even ground
Running on uneven ground
Making sharp turns while running fast
Hopping
Rolling over in bed
COLUMN TOTALS
TO BE COMPLETED BY PHYSICAL THERAPIST/PROVIDER
Score
/80 (No disability 80, SEM 5, MDC 9)
Unable
Severe
Difficulty
Moderate
difficulty
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
A Little
Bit of
Difficulty
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
No
Difficulty
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Adapted from Binkley J et al; Phys Ther; 79: 371-383, 1999.[Prepared Feb 01]
NECK DISABILITY INDEX QUESTIONNAIRE
NAME:
DATE:
PLEASE READ: This questionnaire is designed to give your therapist information as to how your neck pain has affected
your ability to manage in everyday life. Please answer every question by placing a mark on the line that best describes
your condition today. We realize that you may feel that two of the statements may describe your condition, but please
mark only the line which most closely describes your current condition.
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
PERSONAL CARE (Washing, Dressing, etc.)
 I can look after myself normally without causing
extra pain
 I can look after myself normally, but it causes
extra pain
 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 not get dressed, I wash with difficulty and stay
in bed
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, for example 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 very light weights
 I cannot lift or carry anything at all
READING
 I can read as much as I want to with no pain in
my neck
 I can read as much as I want to with slight pain
in my neck
 I can read as much as I want to with moderate
pain in my neck
 I cannot read as much as I want because of
moderate pain in my neck
 I cannot read as much as I want because of
severe pain in my neck.
 I cannot read at all
HEADACHES
 I have no headaches at all
 I have slight headaches which come infrequently
 I have moderate headaches which come
infrequently
 I have moderate headaches which come
frequently
 I have severe headaches which come frequently
 I have headaches almost all the time
CONCENTRATION
 I can concentrate fully when I want to with no
difficulty
 I can concentrate fully when I want to with slight
difficulty
 I have a fair degree of difficulty concentrating
when I want
 I have a lot of difficulty concentrating when I
want
 I have a great deal of difficulty concentrating
when I want
 I cannot concentrate at all
(PLEASE TURN PAGE OVER)
WORK






I can do as much 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
I cannot do any work at all
DRIVING
 I can drive my car without neck pain
 I can drive my car as long as I want with slight pain
in neck
 I can drive my car as long as I want with moderate
pain
 I can’t drive my car as long as I want because of
moderate pain
 I can hardly drive at all because of severe pain in
my neck
 I can’t drive my car at all
SLEEPING
 I have no trouble sleeping
 My sleep Is slightly disturbed (less than 1 hour
sleep loss)
 My sleep is mildly disturbed (1-2 hours’ sleep loss)
 My sleep is moderately disturbed (2-3 hours’ sleep
loss)
 My sleep is greatly disturbed (3-5 hours’ sleep
loss)
 My sleep is completely disturbed (5-7 hours’ sleep
loss)
RECREATION
 I am able to engage in all my recreational activities
with no neck pain at all
 I am able to engage in all my recreational activities
with some pain in my neck
 I am able to engage in most but not all of my usual
recreational activities because of pain in my neck
 I am able to engage in a few of my recreational
activities because of pain in my neck
 I can hardly do any recreational activities because
of pain in my neck
 I can’t do any recreational activities at all
COMMENTS:
TO BE COMPLETED BY PHYSICAL THERAPIST:
SCORE
out of 50 (SEM 5, MDC 7)
Using this system, a score of 10-28% is considered by the authors to constitute mild disability; 30-48% is moderate; 50-68% is severe; 72% or
more is complete
Adapted from Vernon H, Mior S. The Neck Disability Indes: A Study of Reliability and Validity. Journal of Manipulative and Physiological
Therapeutics 1991; 14(7): 409-415.
LOW BACK DISABILITY QUESTIONNAIRE (REVISED OSWESTRY)
NAME:
DATE:
PLEASE READ: This questionnaire is designed to give your therapist information as to how your back pain has affected your ability to
manage in everyday life. Please answer every question by placing a mark on the line that best describes your condition today. We
realize that you may feel that two of the statements may describe your condition, but please mark only the line which most closely
describes your current condition.
PAIN INTENSITY
 I can tolerate the pain without having to use
painkillers
 The pain is bad but I can manage without taking
painkillers
 Painkillers give complete relief from pain
 Painkillers give moderate relief from pain
 Painkillers give very little relief from pain
 Painkillers have no effect on the pain and I do not
use them
PERSONAL CARE (Washing, Dressing, etc.)
 I can look after myself normally without causing
extra pain
 I can look after myself normally, but it causes
extra pain
 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 not get dressed, I wash with difficulty and stay
in bed
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, for example 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 very light weights
 I cannot lift or carry anything at all
WALKING
 Pain does not prevent me from walking any
distance
 Pain prevents me from walking more than one
mile
 Pain prevents me from walking more than onehalf mile
 Pain prevents me from walking more than onequarter 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
SITTING
 I can sit in any chair as long as I like
 I can only sit in my favorite chair as long as I like
 Pain prevents me from sitting more than one
hour
 Pain prevents me from sitting more than 30
minutes
 Pain prevents me from sitting more than 10
minutes
 Pain prevents me from sitting almost all the time
STANDING
 I can stand as long as I want without extra pain
 I can stand as long as I want but it gives extra
pain
 Pain prevents me from standing more than 1
hour
 Pain prevents me from standing more than 30
minutes
 Pain prevents me from standing more than 10
minutes
 Pain prevents me from standing at all
(PLEASE TURN PAGE OVER)
SLEEPING
 Pain does not prevent me from sleeping well
 I can sleep well only by using tablets
 Even when I take tablets I have less than 6 hours
sleep
 Even when I take tablets I have less than 4 hours
sleep
 Even when I take tablets I have less than 2 hours
sleep
 Pain prevents me from sleeping at all
CHANGING DEGREE OF PAIN
 My pain is rapidly getting better
 My pain fluctuates but overall is definitely
getting better
 My pain seems to be getting better but
improvement is slow at the present
 My pain is neither getting better or worse
 My pain is gradually worsening
 My pain is rapidly worsening
SOCIAL LIFE
 My social life is normal and gives 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. dancing
 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
TRAVELING
 I can travel anywhere without extra pain
 I can travel anywhere but it gives me extra pain
 Pain is bad but I manage journeys over 23 hours
 Pain is bad but I manage journeys less than 1 hour
 Pain restricts me to short necessary journeys
under 30 minutes
 Pain prevents me from traveling except to the
doctor or hospital
COMMENTS:
TO BE COMPLETED BY PHYSICAL THERAPIST:
Scoring: Questions are scored on a vertical scale of 0-5.
Total scores and multiply by 2. Divide by number of sections
answered multiplied by 10. A score of 22% or more is considered
Significant activities of daily living disability.
(Score
x2) /
Sections x10) =
% ADL
Reference: Fairbank, Physiotherapy 1981; 66(8); 27103, Hudson-Cook. In Roland, Jenner (eds.), Back Pain New Approaches to
Rehabilitation & Education. Manchester Univ Press, Manchester 1989: 187-204
NAME
DATE
QUICKDASH
Please rate your ability to do the following activities in the last week by circling the number below the appropriate
response.
NO
DIFFICULTY
Open a tight or new jar
Do heavy household chores (e.g. wash walls, floors)
Carry a shopping bag or briefcase
Wash your back
Use a knife to cut food
Recreational activities in which you take some force or
impact through your arm, shoulder or hand (e.g. golf,
hammering, tennis, etc.)
MODERATE
DIFFICULTY
SEVERE
DIFFICULTY
UNABLE
1
2
3
4
5
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
5
5
5
5
5
NOT AT ALL
During the past week, to what extent has your arm, shoulder,
or hand problem interfered with your normal social activities
with family, friends, neighbors or groups?
MILD
DIFFICULTY
SLIGHTLY
MODERATELY
QUITE A
BIT
EXTREMELY
1
2
3
4
5
NOT
LIMITED AT
ALL
SLIGHTLY
LIMITED
MODERATELY
LIMITED
VERY
LIMITED
UNABLE
1
2
3
4
5
NONE
MILD
MODERATE
SEVERE
EXTREME
1
1
2
2
3
3
4
4
5
5
NO
DIFFICULTY
MILD
DIFFICULTY
MODERATE
DIFFICULTY
SEVERE
DIFFICULTY
SO MUCH
DIFFICULTY
THAT I CAN’T
SLEEP
1
2
3
4
5
During the past week, were you limited in your work or other
regular daily activities as a result of your arm, shoulder or hand
problem?
PLEASE RATE THE SEVERITY OF THE FOLLOWING SYMPTONS IN THE
LAST WEEK (circle number)
Arm, shoulder or hand pain
Tingling (pins and needles) in your arm, shoulder or hand
During the past week, how much difficulty have you had
sleeping because of the pain in your arm, shoulder or hand?
TOTAL
QuickDASH DISABILITY/SYMPTOM SCORE=(sum of n responses)-1)x25, where n is equal to the number of completed responses
n
QuickDASH score may not be calculated if there is greater than 1 missing item
TOTAL DISABILITY SYMPTON SCORE
WORK MODULE (OPTIONAL)
The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking
if that is your main work role).
Please indicate what your job/work is:

I do not work (You may skip this section)
PLEASE CIRCLE THE NUMBER THAT BEST DESCRIBES YOUR PHYSICAL ABILITY IN THE PAST WEEK.
DID YOU HAVE ANY DIFFICULTY:
Using your usual technique for your work?
Doing your usual work because of arm, shoulder or hand?
Doing your work as well as you would like?
Spending your usual amount of time doing your work?
TOTAL
NO
DIFFICULTY
MILD
DIFFICULTY
MODERATE
DIFFICULTY
SEVERE
DIFFICULTY
UNABLE
1
2
3
4
5
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
TOTAL WORK MODULE SCORE
SPORTS/PERFORMING ARTS MODULE (OPTIONAL)
The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or
both. If you play more than one sport or instrument (or play both). Please answer with respect to that activity which is most
important to you.
Please indicate the sport or instrument which is most important to you:

I do not play a sport or an instrument (You may skip this section)
PLEASE CIRCLE THE NUMBER THAT BEST DESCRIBES YOUR PHYSICAL ABILITY IN THE PAST WEEK.
DID YOU HAVE ANY DIFFICULTY:
Using your usual technique for your playing your instrument
or sport?
Playing your musical instrument or sport because of arm,
shoulder or hand pain?
Playing your musical instrument or sport as well as you
would like?
Spending your usual amount of time doing your
practicing/playing your instrument or sport?
TOTAL
NO
DIFFICULTY
MILD
DIFFICULTY
MODERATE
DIFFICULTY
SEVERE
DIFFICULTY
UNABLE
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
TOTAL SPORTS/PERFORMING ARTS MODULE SCORE
SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by 4 (number of items); subtract 1; multiply by 25.
An optional module score may not be calculated if there are any missing items.
Institute for Work & Health 2006