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.
Which one of the following best describes the amount of pain you have experienced during the past 6 months?
None
Mild
Moderate
Moderate to Severe
Severe
Which one of the following best describes the amount of pain you have experienced over the last month?
None
Mild
Moderate
Moderate to Severe
Severe
During the past 6 months have you been a very nervous person?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
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?
Very Happy
Somewhat Happy
Neither Happy or Unhappy
Somewhat Happy
Very Unhappy
What is your current level of activity?
Bedridden
Primarily no activity
Light labor and light sports
Moderate labor and moderate sports
Full activities without restriction
How do you look in clothes?
Very Good
Good
Fair
Bad
Very Bad
In the past 6 months have you felt so down in the dumps that nothing could cheer you up?
Very Often
Often
Sometimes
Rarely
Never
Do you experience back pain when at rest?
Very Often
Often
Sometimes
Rarely
Never
What is your current level of work/school activity?
100% Normal
75% Normal
50% Normal
25% Normal
0% Normal
Which of the following best describes the appearance of your trunk; defined as the human body except for the head and extremities?
Very Good
Good
Fair
Poor
Very Poor
Which one of the following best describes your pain medication use for back pain?
None
Non-narcotics weekly or less (e.g., aspirin, Tylenol, Ibuprofen)
Non-narcotics daily
Narcotics weekly or less (e.g. Endone, Oxycontin orally or, Norspan , Durogesic patches)
Narcotics daily
Does your back limit your ability to do things around the house?
Never
Rarely
Sometimes
Often
Very Often
Have you felt calm and peaceful during the past 6 months?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
Do you feel that your back condition affects your personal relationships?
None
Slightly
Mildly
Moderately
Severely
Are you and/or your family experiencing financial difficulties because of your back?
Severely
Moderately
Mildly
Slightly
None
In the past 6 months have you felt down hearted and blue?
Never
Rarely
Sometimes
Often
Very Often
In the last 3 months have you taken any days off of work, including household work, or school because of back pain?
0 days
1 day
2 days
3 days
4 or more days
Does your back condition limit your going out with friends/family?
Never
Rarely
Sometimes
Often
Very Often
Do you feel attractive with your current back condition?
Yes, very
Yes, somewhat
Neither attractive nor unattractive
No, not very much
No, not at all
Have you been a happy person during the past 6 months?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
Are you satisfied with the results of your back management?
Very Satisfied
Satisfied
Neither Satisfied or Unsatisfied
Unsatisfied
Very Satisfied
Would you have the same management again if you had the same condition?
Definitely Yes
Probably Yes
Not Sure
Probably Not
Definitely Not
Thank you for completing this questionnaire. Please comment if you wish.