PAIN

INTEN

SITYSITTIN

GR

EAD

ING

I have no pain at the momentI can sit in a chair as long as I like

The pain is very mild at the moment

The pain is moderate at the momentPain prevents me sitting more than 1 hour

The pain is fairly severe at the momentPain prevents me sitting more than 30 min.

The pain is very severe at the momentPain prevents me sitting more than 10 min

The pain is the worst imaginable .Pain prevents me sitting at all.

I cannot read at all.PER

SON

AL C

AR

E STA

ND

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TRA

VELLIN

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I can stand as long as I want w/o extra pain.I can travel anywhere w/o pain.

It is painful to look after myself and

I am slow and carefulPain restricts me to trips of less than 1 hr.

Pain prevents me from standing at all.I do not get dressed, wash with difficulty. Port Orange Family Chiropractic Center

4606 Clyde Morris Blvd., 1M Port Orange, FL 32129386-756-9303

I can read as much as I want w/o neck pain.

I can only sit in my favorite chair as long as I like.

I can read as much as I want with slight neck pain.I can read as much as I want w/moderate neck pain.I can't read as much as I want because of moderate neck pain.I can hardly read at all because of severe pain in the neck.

I can look after myself normally w/o causing extra pain.I can look after myself normally but it causes cause pain.

I can stand as long as I want but it gives me extra pain.

I can travel anywhere but it gives me extra pain.

Pain prevents me from standing more than 1 hour.

Pain is bad but I manage trips over 2 hours.

Pain prevents me from standing more than 30 minutes.

I need some help but manage most of my personal care.

Pain prevents me from standing more than 10 minutes.

Pain restricts me to short necessary trips under 30 minutes.

I need help every day in most aspects of self-care.

Pain prevents me from traveling except to receive treatment.

LIFTING

SLEEPING

SOC

IAL LIFE

I can lift heavy weights without extra pain.My sleep is never disturbed by pain

My sleep is occasionally disturbed by pain

Because of pain I sleep less than 6 hours

Because of pain I sleep less than 4 hours

I can lift light weightsBecause of pain I sleep less than 2 hours

I cannot lift or carry anything at all.Pain prevents me from sleeping at all.

I have no social life because of the pain.WALK

ING

DRIV

ING

I can drive my car w/o any pain ( neck)

I can only walk using a stick or crutchesI am in bed most of the time.

I can't drive my car at all.

My social life is normal and gives me no extra pain.

I can lift heavy weights but it gives extra pain.

My social life is normal but increases the degree of pain.

Pain prevents me from lifting weights off the floor, but can manage if on a table.

Pain has no significant effect on my social life apart from limiting sports.

Pain prevents me from lifting weights, but I can lift light to medium weights.

Pain has restricted my social life and I do not go out as often.Pain has restricted my social life to my home.

Pain does not prevent me walking any distance.Pain prevents me from walking more than 1 mile.

I can drive my car as long as I want with slight pain (neck)

Pain prevents me from walking more than 1/2 a mile.

I can drive my car as long as I want with moderate pain (neck)

Paine prevents me from walking more than 100 yards.

I can't drive my car as long as I want because of moderate pain (neck).I can hardly drive my car at all because of severe pain (neck)