Scoliosis Patient Questionnaire: Modified 11/12/03

Version 30 (Encompasses Versions 22 and 24)

Patient Name:_____________________________________Age:________ Date:________________
Medical Record #_____________________________ SS:___________________________________
Exam: Pre-treatment 3 mos. 6 mos. 1 year _____ years
Your doctors are carefully evaluating the condition of your back before and after your treatment. Please circle the
one best answer to each question unless otherwise indicated. If you already have had surgery, please complete
sections 1 and 2. Otherwise, just complete section 1.

All results will be kept confidential.

Section 1: All patients
1. Which one of the following best describes the 7. In the past 6 months have you felt so down
amount of pain you have experienced during in the dumps that nothing could cheer you
the past 6 months? up?
£ None £ Moderate to severe £ Very often £ Rarely
£ Mild £ Severe £ Often £ Never
£ Moderate £ Sometimes

2. Which one of the following best describes the 8. Do you experience back pain when at rest?
amount of pain you have experienced over £ Very often £ Rarely
the last month? £ Often £ Never
£ None £ Moderate to severe £ Sometimes
£ Mild £ Severe
£ Moderate 9. What is your current level of work/school
activity?
3. During the past 6 months have you been a £ 100% normal £ 25% normal
very nervous person? £ 75% normal £ 0% normal
£ None of the time £ Most of the time £ 50% normal
£ A little of the time £ All of the time
£ Some of the time 10. Which of the following best describes the
appearance of your trunk; defined as the
4. If you had to spend the rest of your life with human body except for the head and
your back shape as it is right now, how would extremities?
you feel about it? £ Very good £ Poor
£ Very happy £ Somewhat unhappy £ Good £ Very poor
£ Somewhat happy £ Very unhappy £ Fair
£ Neither happy nor unhappy
11. Which one of the following best describes
5. What is your current level of activity? your medication usage for your back?
£ Bedridden/wheelchair £ None
£ Primarily no activity £ Non-narcotics weekly or less
£ Light labor, such as household chores (e.g., Tylenol, Ibuprofen)
£ Moderate manual labor and moderate sports, £ Non-narcotics daily
such as walking and biking £ Narcotics weekly or less
£ Full activities without restriction (e.g., Percocet, Lorcet, Codeine, Darvocet)
£ Narcotics daily
6. How do you look in clothes? £ Other (please specify below)
£ Very good Medication:
£ Good ____________________________________
£ Fair Usage (weekly or less or daily):
£ Bad ____________________________________
£ Very bad
12. Does your back limit your ability to do things 21. Are you satisfied with the results of your
around the house? back management?
£ Never £ Often £ Very satisfied £ Unsatisfied
£ Rarely £ Very often £ Satisfied £ Very unsatisfied
£ Sometimes £ Neither satisfied nor unsatisfied

13. Have you felt calm and peaceful during the 22. Would you have the same management
past 6 months? again if you had the same condition?
£ All of the time £ A little of the time £ Definitely yes £ Probably not
£ Most of the time £ None of the time £ Probably yes £ Definitely not
£ Some of the time £ Not sure
23. On a scale of 1 to 9, with 1 being very low
14. Do you feel that your back condition affects and 9 being extremely high, how would you
your personal relationships? rate your self-image?
£ None £ Moderately
£ Slightly £ Severely £1 £2 £3 £4 £5 £6 £7 £8 £9
£ Mildly

15. Are you and/or your family experiencing Section 2: Post-surgery patients only
financial difficulties because of your back?
£ Severely £ Slightly 24. Compared with before treatment, how do
£ Moderately £ None you feel you now look?
£ Mildly £ Much better £ Worse
£ Better £ Much worse
16. In the past 6 months have you felt down- £ Same
hearted and blue?
£ Never £ Often 25. Has your back treatment changed your
£ Rarely £ Very often function and daily activity?
£ Sometimes £ Increased £ Not changed £ Decreased
17. In the last 3 months have you taken any sick 26. Has your back treatment changed your
days from work/school due to back pain and, ability to enjoy sports/hobbies?
if so, how many? £ Increased £ Not changed £ Decreased
£0 £1 £2 £3 £ 4 or more 27. Has your back treatment ________________
your back pain?
18. Do you go out more or less than your friends? £ Increased £ Not changed £ Decreased
£ Much more £ Less
£ More £ Much less 28. Has your treatment changed your
£ Same confidence in personal relationships with
others?
19. Do you feel attractive with your current back £ Increased £ Not changed £ Decreased
condition?
£ Yes, very £ No, not very much 29. Has your treatment changed the way others
£ Yes, somewhat £ No, not at all view you?
£ Neither attractive nor unattractive £ Much better £ Worse
£ Better £ Much worse
20. Have you been a happy person during the £ Same
past 6 months?
£ None of the time £ Most of the time 30. Has your treatment changed your self-
£ A little of the time £ All of the time image?
£ Some of the time £ Increased £ Not changed £ Decreased
Please mark on the drawings any areas where you feel pain. If you are not having any pain, leave
blank and initial.

Use the following key to show particular types of pain

KEY:

Pins & needles = 000000

Burning = XXXXXX
Stabbing = //////
Deep ache = ZZZZZZ