Patient Follow-Up Questionnaire:

Patient Follow-Up Questionnaire

2. How often do you experience your symptoms?
Indicate where you have pain or other symptoms:
3. What describes the nature of your symptoms?
4. How are your symptoms changing?
6. How do your symptoms affect your ability to perform daily activities?
7. What do you hope to get from your visit/treatment (select all that apply):

NECK DISABILITY INDEX

This questionnaire will give your provider information about how your neck condition affects your everyday life. Pleaseanswer every section by circling the one statement that applies to you. If two or more statements in one section apply,please mark the one statement that most closely describes your problem.

Section 1: Pain Intensity*
Please select one option
Section 2--Personal Care*
Please select one option
Section 3--Lifting*
Please select one option
Section 4- Work*
Please select one option
Section 5 -Headaches*
Please select one option
Section 6- Concentration*
Please select one option
Section 7- Sleeping
Section 8- Driving*
Please select one option
Section 9- Reading*
Please select one option
Section 10- Recreation*
Please select one option

BACK DISABILITY INDEX

This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by circling the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.

Pain Intensity
Personal Care
Sleeping
Lifting
Sitting
Traveling
Standing
Social Life
Walking
Changing degree of pain

Thank you for taking the time to fill out this form.


Our Location

2215 Jordan Ave. The condos behind McDonalds and Jordan Creek Mall. We are the 3rd building on the right, on the one-way street.

Office Hours

Massage times may differ from Front Office times

Open

Monday:

8:30 am-12:00 pm

2:00 pm-5:00 pm

Tuesday:

8:30 am-12:00 pm

Wednesday:

8:30 am-12:00 pm

2:00 pm-5:00 pm

Thursday:

8:30 am-12:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed