Cervical Spine Well Assessment

Welcome to the Cervical Spine Wellness Assessment! This tool offers a quick and thorough evaluation of your Cervical Spine health. By examining key aspects of functionality, strength, and mobility, you'll gain essential insights to help maintain and enhance your Cervical Spine wellness. Start now to take the first step towards optimal Cervical Spine health!

Score: 0 / 50 or 0%

Patient Identifier:

Date completed:

Section 1: 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

Section 2: 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 but I am slow and careful I need some help but can 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

Section 3: 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 (e.g. 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

Section 4: Walking

Pain does not prevent me from walking any distance Pain prevents me from walking more than 1 mile Pain prevents me from walking more than 1/2 mile Pain prevents me from walking more than 1/4 mile I can walk only with crutches or a cane I am in bed most of the time and have to crawl to the toilet

Section 5: 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 1 hour Pain prevents me from sitting more than 1/2 hour Pain prevents me from sitting more than 10 minutes I avoid sitting because it increases pain immediately

Section 6: Standing

I can stand as I like I can only stand as long as I like Pain prevents me from Standing more than 1 hour Pain prevents me from Standing more than 1/2 hour Pain prevents me from Standing more than 10 minutes I avoid Standing because it increases pain immediately

Section 7: Sleeping

I can sleep as I like I can only sleep as long as I like Pain prevents me from Sleeping more than 1 hour Pain prevents me from Sleeping more than 1/2 hour Pain prevents me from Sleeping more than 10 minutes I avoid Sleeping because it increases pain immediately

Section 8: Stairs

Normally without using a railing Normally using a railing In any manner Unable to do stairs Pain prevents me from doing I avoid because it increases pain immediately

Section 9: Social Life

I can involve as I like I can only involve as long as I like Pain prevents me from involving more peoples Pain prevents me from involving more peoples comfort Pain prevents me from involving more peoples Severe I avoid involving because it increases pain immediately

Section 10: Travelling

I can travel as I like I can only travel as long as I like Pain prevents me from Travelling more than 1 hour Pain prevents me from Travelling more than 2 day Pain prevents me from Travelling more than 10 days I avoid Travelling because it increases pain immediately

Progress Report

Cervical Score

Cervical Spine Well Assessment

Patient Identifier:

Date completed:

Section 1: Pain Intensity

Section 2: Personal Care (Washing, Dressing, etc.)

Section 3: Lifting

Section 4: Walking

Section 5: Sitting

Section 6: Standing

Section 7: Sleeping

Section 8: Stairs

Section 9: Social Life

Section 10: Travelling

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Cervical Score

Cervical Spine Well Assessment

Patient Identifier:

Date completed:

Section 1: Pain Intensity

Section 2: Personal Care (Washing, Dressing, etc.)

Section 3: Lifting

Section 4: Walking

Section 5: Sitting

Section 6: Standing

Section 7: Sleeping

Section 8: Stairs

Section 9: Social Life

Section 10: Travelling

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