Services & Conditions - Physical therapy New Jersey

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Question 1: Pain Intensity *I have no pain at the momentThe pain is very mild at the momentThe pain is moderate at the momentThe pain is fairly severe at the momentThe pain is very severe at the momentThe pain is the worst imaginable at the moment

Question 6: Standing *I can stand as long as I want without extra painI can stand as long as I want but it gives me extra painPain prevents me from standing for more than 1 hourPain prevents me from standing for more than 30 minutesPain prevents me from standing for more than 10 minutesPain prevents me from standing at all

Question 2: Personal Care (Washing, Dressing, etc.) *I can look after myself normally without causing extra painI can look after myself normally but it causes extra painIt is painful to look after myself and I am slow and carefulI need some help but can manage most of my personal careI need help every day in most aspects of self-careI do not get dressed, I wash with difficulty and stay in bed

Question 7: Sleeping *My sleep is never disturbed by painMy sleep is occasionally disturbed by painBecause of pain, I have less than 6 hours sleepBecause of pain, I have less than 4 hours sleepBecause of pain, I have less than 2 hours sleepPain prevents me from sleeping at all

Question 3: Lifting *I can lift heavy weights without extra painI can lift heavy weights but it gives extra painPain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placedPain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positionedI can only lift very light weightsI cannot lift or carry anything

Question 8: Sex Life (if applicable) *My sex life is normal and causes no extra painMy sex life is normal but causes some extra painMy sex life is nearly normal but is very painfulMy sex life is severely restricted by painMy sex life is nearly absent because of painPain prevents any sex life at all

Question 4: Walking *Pain does not prevent me walking any distancePain prevents me from walking more than 1 milePain prevents me from walking more than ½ milePain prevents me from walking more than 100 yardsI can only walk using a stick or crutchesI am in bed most of the time

Question 9: Social Life *My social life is normal and gives me no extra painMy social life is normal but increases the degree of painPain has no significant effect on my social life apart from limiting my more energetic interests, for example, sportPain has restricted my social life and I do not go out as oftenPain has restricted my social life to my homeI have no social life because of pain

Question 5: Sitting *I can sit in any chair as long as I likeI can only sit in my favorite chair as long as I likePain prevents me from sitting more than 1 hourPain prevents me from sitting more than 30 minutesPain prevents me from sitting more than 10 minutesPain prevents me from sitting at all

Question 10: Traveling *I can travel anywhere without painI can travel anywhere but it gives me extra painPain is bad but I manage journeys over two hoursPain restricts me to journeys of less than 1 hourPain restricts me to short necessary journeys under 30 minutesPain prevents me from traveling except to receive treatment

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Current Date

Please rate your ability to do the following activities in the last week:

Question 2: What amount of knee pain have you experienced the last week during the following activities; Walking on a flat surface? *NoneMildModerateSevereExtreme

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Please rate your ability to do the following activities in the last week:

Question 2: What amount of hip pain have you experienced the last week during the following activities; Walking on a flat surface? *NoneMildModerateSevereExtreme

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Current Date

Please rate your ability to do the following activities in the last week:

Question 6: Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g., golf, hammering, tennis, etc.). *No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnable

Question 7: 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? *No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnable

Question 8: 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? *No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnable

Question 9: In the last week, please rate the severity of arm, shoulder, or hand pain. *No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnable

Question 10: In the last week, please rate the severity of tingling (pins and needles) in your arm, shoulder, or hand. *No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnable

Question 11: During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? *No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnable

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Question 1: Any of your usual work, housework, or school activities *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 11: Walking 2 blocks. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 2: Your usual hobbies, recreational, or sporting activities. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 12: Walking a mile. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 3: Getting into or out of the bath. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 13: Going up or down 10 stairs (about 1 flight of stairs). *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 4: Walking between rooms. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 14: Standing for 1 hour. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 5: Putting on your shoes or socks. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 15: Sitting for 1 hour. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 6: Squatting *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 16: Running on even ground. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 7: Lifting an object, like a bag of groceries from the floor. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 17: Running on uneven ground. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 8: Performing light activities around your home. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 18: Making sharp turns while running fast. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 9: Performing heavy activities around your home. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 19: Hopping. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 10: Getting into or out of a car. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Question 20: Rolling over in bed. *No difficultyA little bit of difficultyModerate difficultyQuite a bit of difficultyExtreme difficulty or unable to perform activity

Lower Extremity Functional Score

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Question 6: Concentration *I can concentrate fully when I want to with no difficultyI can concentrate fully when I want to with slight difficultyI have a fair degree of difficulty in concentrating when I want toI have a lot of difficulty in concentrating when I want toI have a great deal of difficulty in concentrating when I want toI cannot concentrate at all

Question 7: Work *I can do as much work as I want toI can only do my usual work, but no moreI can do most of my usual work, but no moreI can’t do my usual workI can hardly do any work at allI can’t do any work at all

Question 8: Driving *I can drive my car without any neck painI can drive my car as long as I want with slight pain in my neckI can drive my car as long as I want with moderate pain in my neckI can’t drive my car as long as I want because of moderate pain in my neckI can hardly drive at all because of severe pain in my neckI can’t drive my car at all

Question 4: Reading *I can read as much as I want to with no pain in my neckI can read as much as I want to with slight pain in my neckI can read as much as I want with moderate pain in my neckI can’t read as much as I want because of moderate pain in my neckI can hardly read at all because of severe pain in my neckI cannot read at all

Question 9: Sleeping *I have no trouble sleepingMy sleep is slightly disturbed (less than 1 hr sleepless)My sleep is mildly disturbed (1-2 hours sleepless)My sleep is moderately disturbed (2-3 hours sleepless)My sleep is greatly disturbed (3-5 hours sleepless)My sleep is completely disturbed (5-7 hours sleepless)

Question 5: Headaches *I have no headaches at allI have slight headaches, which come infrequentlyI have moderate headaches, which come infrequentlyI have moderate headaches, which come frequentlyI have severe headaches, which come frequentlyI have headaches almost all the time

Question 10: Recreation *I am able to engage in all my recreation activities with no neck pain at allI am able to engage in all my recreation activities, with some pain in my neckI am able to engage in most, but not all of my usual recreation activities because of pain in my neckI am able to engage in a few of my usual recreation activities because of pain in my neckI can hardly do any recreation activities because of pain in my neckI can’t do any recreation activities at all

Neck Disability Index Score

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