Self-Assessment: Neck & Back Pain — Coffeyville Regional Medical Center

The following questions will help you learn if you can benefit from therapeutic intervention to address your neck or back pain.

How to Use This Self-Assessment

For each question, select the choice that best applies to you.

Do you have neck or back pain that limits you performing daily functional activities? (e.g.: dressing, bathing, toileting)
Do you have neck or back pain that restricts you from performing any recreational activities? (e.g.: hiking, sports)
Do you have neck or back pain that restricts you from performing any daily household activities? (e.g.: laundry, vacuuming, cleaning)
Do you have pain at night that significantly interferes with your sleeping?
Do you have any of the following symptoms in your arms or legs: pain, burning, shooting pain, ache/numbness, tingling?
Have you noticed weakness in your arms or legs?
Have you noticed significant loss of balance or difficulty walking?
Do you have a weakness in the foot or “foot drop?”
Have you experienced loss of bowel or bladder control?