Today M-D-Y
First Name
* must provide value
Last Name
* must provide value
Medical Record #
* must provide value
Blue Card #
Date of Birth
* must provide value
Today Y-M-D
Male
Female
Caucasian
African American
Hispanic
Asian
Middle Eastern
Other
I am receiving my care at:
* must provide value
Brigham & Women's Hospital
Massachusetts General Hospital
Provider's Name
* must provide value
Dr. Cha
Dr. Binder
Dr. Gilligan
Dr. Grottkau
Dr. Mansfield
Dr. Pedlow
Dr. Rathmell
Dr. Sarni
Dr. Schwab
Dr. Shinchuk
Dr. Wood
Lisa Beyer, P.A.
Provider's Name:
* must provide value
Dr. Bono
Dr. Harris
Dr. Ferrone
Dr. Groff
Dr. Chi
The JOA Cervical Myelopathy Evaluation Questionnaire: With regard to your health condition during the last week, please select the answer for the following questions that best applies. If your condition varies depending on the day or the time, select the answer describing your condition at its worst.
While in the sitting position, can you look up at the ceiling by tilting your head upward?
* must provide value
Impossible
Possible to some degree (with some efforts)
Possible without difficulty
Can you drink a glass of water without stopping despite the neck symptoms?
* must provide value
Impossible
Possible to some degree
Possible without difficulty
While in the sitting position, can you turn your head toward the person who is seated to the side
but behind you and speak to that person while looking at his/her face?
* must provide value
Impossible
Possible to some degree
Possible without difficulty
Can you look at your feet when you go down the stairs?
* must provide value
Impossible
Possible to some degree
Possible without difficulty
Can you fasten the front buttons of your blouse or shirt with both hands?
* must provide value
Impossible
Possible if I spend time
Possible without difficulty
Can you eat a meal with your dominant hand using a spoon or a fork?
* must provide value
Impossible
Possible if I spend time
Possible without difficulty
Can you raise your arm? (Answer for the weaker side.)
* must provide value
Impossible
Possible up to shoulder level
Possible though the elbow and/or wrist is a little flexed
I can raise it straight upward
Can you walk on a flat surface?
* must provide value
Impossible
Possible but slowly even with support
Possible only with the support of a handrail, a cane, or a walker
Possible but slowly without any support
Possible without difficulty
Can you stand on either leg without the support of your hand?
(the need to support yourself)
* must provide value
Impossible with either leg
Possible on either leg for more than ten seconds
Possible on both legs individually for more than ten seconds
Do you have difficulty in going up the stairs?
* must provide value
I have great difficulty.
I have some difficulty.
I have no difficulty.
Do you have difficulty in one of the following motions; bending forward, kneeling or stooping?
* must provide value
I have great difficulty.
I have some difficulty.
I have no difficulty.
Do you have difficulty in walking more than 15 minutes?
* must provide value
I have great difficulty.
I have some difficulty.
I have no difficulty.
Do you have urinary incontinence?
* must provide value
Always
Frequently
When retaining urine over a period of more than 2 hours
When sneezing or straining
No
How often do you go to the bathroom at night?
* must provide value
Three times or more
Once or twice
Rarely
Do you have a feeling of residual urine in your bladder after voiding?
* must provide value
Most of the time
Sometimes
Rarely
Can you initiate (start) your urine stream immediately when you want to void?
* must provide value
Usually not
Sometimes
Most of the time
What is the purpose of your visit?
* must provide value
Neck Pain
Low Back Pain
Scoliosis/Deformity
Cancer
EQ-5D: This is the EQ-5D, a questionnaire that helps us get a better idea of your health in general.
Mobility:
* must provide value
I have no problems in walking about.
I have some problems in walking about.
I am confined to bed.
Self Care:
* must provide value
I have no problems with self-care.
I have some problems washing or dressing myself.
I am unable to wash or dress myself.
Usual Activities (e.g. work, study, housework, family or leisure activities):
* must provide value
I have no problems with performing my usual activities.
I have some problems with performing my usual activities.
I am unable to perform my usual activities.
Pain Discomfort:
* must provide value
I have no pain or discomfort.
I have moderate pain or discomfort.
I have extreme pain or discomfort.
Anxiety Depression:
* must provide value
I am not anxious or depressed.
I am moderately anxious or depressed.
I am extremely anxious or depressed.
To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0.
Please indicate on this scale how good or bad your own health is today, in your opinion.
* must provide value
NDI: This is the Neck Disability Index, a questionnaire that helps us get a better idea of how your neck pain affects your life.
1. Pain Intensity:
* must provide value
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.
2. Personal Care (Washing, Dressing, etc.):
* must provide value
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 and I am slow and careful.
I need some help, but 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.
3. Lifting:
* must provide value
I can lift heavy weights without causing extra pain.
I can lift heavy weights, but it gives me extra pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example on a table.
Pain prevents me from lifting heavy weights off the floor, 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.
4. Reading:
* must provide value
I can read as much as I want to with no pain in my neck.
I can read as much as I want to with slight pain in my neck.
I can read as much as I want with moderate pain in my neck.
I can't read as much as I want because of moderate pain in my neck.
I can hardly read at all because of severe pain in my neck.
I cannot read at all.
5. Headaches:
* must provide value
I have no headaches at all.
I have slight headaches that come infrequently.
I have moderate headaches that come infrequently.
I have moderate headaches that come frequently.
I have severe headaches that come frequently.
I have headaches almost all the time.
6. Concentration:
* must provide value
I can concentrate fully when I want to, with no difficulty.
I can concentrate fully when I want to, with slight difficulty.
I have a fair degree of difficulty in concentrating when I want to.
I have a lot of difficulty in concentrating when I want to.
I have a great deal of difficulty in concentrating when I want to.
I cannot concentrate at all.
7. Work:
* must provide value
I can do as much work as I want to.
I can only do my usual work, but no more.
I can do most of my usual work, but no more.
I cannot do my usual work.
I can hardly do any work at all.
I can't do any work at all.
8. Driving:
* must provide value
I can drive my car without any neck pain.
I can drive my car as long as I want with slight pain in my neck.
I can drive my car as long as I want with moderate pain in my neck.
I can't drive my car as long as I want because of moderate pain in my neck.
I can hardly drive at all because of severe pain in my neck.
I can't drive my car at all.
9. Sleeping:
* must provide value
I have no trouble sleeping.
My sleep is slightly disturbed (less than 1 hr sleepless).
My sleep is mildly disturbed (1-2 hrs sleepless).
My sleep is moderately disturbed (2-3 hrs sleepless).
My sleep is greatly disturbed (3-5 hrs sleepless).
My sleep is completely disturbed (5-7 hrs sleepless).
10. Recreation:
* must provide value
I am able to engage in all my recreation activities with no neck pain at all.
I am able to engage in all my recreation activities, with some pain in my neck.
I am able to engage in most, but not all of my usual recreation activities because of pain in my neck.
I am able to engage in a few of my usual recreation activities because of pain in my neck.
I can hardly do any recreation activities because of pain in my neck.
I can't do any recreation activities at all.
ODI: This is the Oswestry Disability Index for back pain, a questionnaire that helps us get a better idea of how your back pain affects your life.
ODI - Pain Intensity:
* must provide value
My pain is mild to moderate. I do not need pain killers.
The pain is bad, but I manage without taking pain killers.
Pain killers give complete relief from pain.
Pain killers give moderate relief from pain.
Pain killers give very little relief from pain.
Pain killers have no effect on the pain.
ODI - Personal Care:
* must provide value
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 and I am slow and careful.
I need some help but 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.
ODI - Lifting:
* must provide value
I can lift heavy weights without causing extra pain.
I can lift heavy weights but it gives me extra pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example 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.
ODI - Walking:
* must provide value
I can walk as far as I wish.
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 if I use a cane or crutches.
I am in bed or in a chair for most of every day.
ODI - Sitting:
* must provide value
I can sit in any chair for as long as I like.
I can sit in my favorite chair only, but for as long as I like.
Pain prevents me from sitting for more than 1 hour.
Pain prevents me from sitting for more than 1_2 hour.
Pain prevents me from sitting for more than 10 minutes.
Pain prevents me from sitting at all.
ODI - Standing:
* must provide value
I can stand as long as I want without extra pain.
I can stand as long as I want, but it gives me extra pain.
Pain prevents me from standing for more than 1 hour.
Pain prevents me from standing for more than 1_2 hour.
Pain prevents me from standing for more than 10 minutes.
Pain prevents me from standing at all.
ODI - Sleeping:
* must provide value
Pain does not prevent me from sleeping well.
I sleep well but only when taking medicine.
Even when I take medication, I sleep less than 6 hours.
Even when I take medication, I sleep less than 4 hours.
Even when I take medication, I sleep less than 2 hours.
Pain prevents me from sleeping at all.
ODI - Employment/Housemaking
* must provide value
My normal homemaking/job activities do not cause me pain.
My normal homemaking/job activities increase my pain, but I can still perform all that is required of me.
I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (e.g., lifting, vacuuming).
Pain prevents me from doing anything but light duties.
Pain prevents me from doing even light duties.
Pain prevents me from performing any job or housemaking chores.
ODI - Social Life:
* must provide value
My social life is normal and causes me no extra pain.
My social life is normal, but increases the degree of pain.
Pain affects my social life by limiting only my more energetic interests, such as dancing, sports, etc.
Pain has restricted my social life and I do not go out as often.
Pain has restricted my social life to my home.
I have no social life because of pain.
ODI - Traveling:
* must provide value
I can travel anywhere without extra pain.
I can travel anywhere, but it gives me extra pain.
Pain is bad, but I manage journeys over 2 hours.
Pain restricts me to journeys of less than 1 hour.
Pain restricts me to necessary journeys under 1_2 hour.
Pain prevents traveling except to the doctor_hospital.
SRS-22: This is the SRS-22, a questionnaire that helps us get a better idea of how scoliosis or deformity is affecting your life.
1. Which one of the following best describes the amount of pain you have experienced over the last 6 months?
* must provide value
None
Mild
Moderate
Moderate to severe
Severe
2. Which one of the following best describes the amount of pain you have experienced over the last month?
* must provide value
None
Mild
Moderate
Moderate to severe
Severe
3. During the past 6 months have you been a very nervous person?
* must provide value
None of the time
A little of the time
Some of the time
Most of the time
All of the time
4. If you had to spend the rest of your life with your back shape as it is right now, how would you feel about it?
* must provide value
Very happy
Somewhat happy
Neither happy nor unhappy
Somewhat unhappy
Very unhappy
5. What is your current level of activity?
* must provide value
Bedridden/Wheelchair
Primarily no activity
Light labor, such as household chores
Moderate manual labor and moderate sports, such as walking and biking
Full activities without restriction
6. How do you look in clothes?
* must provide value
Very good
Good
Fair
Bad
Very bad
7. In the past 6 months have you felt so down in the dumps that nothing could cheer you up?
* must provide value
Very often
Often
Sometimes
Rarely
Never
8. Do you experience back pain when at rest?
* must provide value
Very often
Often
Sometimes
Rarely
Never
9. What is your current level of work_school activity?
100% normal
75% normal
50% normal
25% normal
0% normal
10. Which of the following best describes the appearance of your trunk; defined as the human body except for the head and extremities.
* must provide value
Very good
Good
Fair
Poor
Very Poor
11. Which one of the following best describes your medication usage for your back?
* must provide value
None
Non-narcotics weekly or less (e.g., aspirin, Tylenol, Ibuprofen)
Non-narcotics daily
Narcotics weekly or less (e.g. Tylenol III, Lorocet, Percocet)
Narcotics daily
12. Does your back limit your ability to do things around the house?
* must provide value
Never
Rarely
Sometimes
Often
Very often
13. Have you felt calm and peaceful during the past 6 months?
* must provide value
All of the time
Most of the time
Some of the time
A little of the time
None of the time
14. Do you feel that your back condition affects your personal relationships?
* must provide value
None
Slightly
Mildly
Moderately
Severely
15. Are you and/or your family experiencing financial difficulties because of your back?
* must provide value
Severely
Moderately
Mildly
Slightly
None
16. In the past 6 months have you felt down hearted and blue?
* must provide value
Never
Rarely
Sometimes
Often
Very often
17. In the last 3 months have you taken any sick days from work/school due to back pain and if so how many?
* must provide value
0
1
2
3
4 or more
18. Do you go out more or less than your friends?
* must provide value
Much more
More
Same
Less
Much less
19. Do you feel attractive?
* must provide value
Yes, very
Yes, somewhat
Neither attractive nor unattractive
No, not very much
No, not at all
20. Have you been a happy person during the past 6 months?
* must provide value
None of the time
A little of the time
Some of the time
Most of the time
All of the time
21. Are you satisfied with the results of your back management?
* must provide value
Very satisfied
Satisfied
Neither satisfied nor unsatisfied
Unsatisfied
Very unsatisfied
22. Would you have the same management again if you had the same condition?
* must provide value
Definitely yes
Probably yes
Not sure
Probably not
Definitely not
View equation
FACT-G: This is the FACT-G, a questionnaire that helps us get a better idea of how your condition and its treatment are affecting your life.
FACT-G: PHYSICAL WELL-BEING
1. I have a lack of energy
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
2. I have nausea
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
3. Because of my physical condition, I have trouble
meeting the needs of my family
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
4. I have pain
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
5. I am bothered by side-effects of treatment
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
6. I feel ill
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
7. I am forced to spend time in bed
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
8. I feel close to my friends
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
9. I get emotional support from my family
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
10. I get support from my friends
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
11. My family has accepted my illness
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
12. I am satisfied with family communication about my illness
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
13. I feel close to my partner(or the person who is my main support)
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
14. I am satisfied with my sex life
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
Prefer not to answer
15. I feel sad
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
16. I am satisfied with how I am coping with my illness
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
17. I am losing hope in the fight against my illness
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
18. I feel nervous
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
19. I worry about dying
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
20. I worry that my condition will get worse
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
21. I am able to work(include work at home)
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
22. My work(include work at home) is fulfilling
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
23. I am able to enjoy life
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
24. I have accepted my illness
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
25. I am sleeping well
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
26. I am enjoying the things I usually do for fun
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
27. I am content with the quality of my life right now
* must provide value
Not at All
A Little Bit
Somewhat
Quite a Bit
Very Much
Spine Oncology Study Group Self-Assessment Questionnaire: This is the SOSG Self-Assessment Questionnaire, a questionnaire that helps us get a better idea of how your cancer and its treatment are affecting your life.
I. Physical Function (5-point scale)
1. What is your current level of
activity?
* must provide value
Full activities without restriction (1 pt)
Moderate activities out of house (2 pts)
Mobility limited to within house (3 pts)
Bed to chair activity (4 pts)
Bedridden (5 pts)
2. What is your ability to work
(including at home)_ study?
* must provide value
Unlimited (1 pt)
4-8 hours per day (2 pts)
2-4 hours p (3 pts)
Less than 2 hours per day (4 pts)
Not at all (5 pts)
3. Does your spine limit your ability to
care for yourself?
* must provide value
Not at all (1 pt)
A little bit (2 pts)
Somewhat (3 pts)
Quite a bit (4 pts)
Very Much (5 pts)
4. Do you require assistance from
others to travel outside of the home?
* must provide value
Never (1 pts)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Very Often (5 pts)
II. Neurological Function (5-point scale)
5. Do you have weakness in your legs?
* must provide value
None (1 pts)
Mild Occasionally (2 pts)
Mild Constantly(3 pts)
Moderate Constantly (4 pts)
Severe Constantly (5 pts)
6. Do you have weakness in your arms?
* must provide value
None (1 pts)
Mild Occasionally (2 pts)
Mild Constantly(3 pts)
Moderate Constantly (4 pts)
Severe Constantly (5 pts)
7. What assistance do you need with your
walking?
* must provide value
None (1 pts)
A Cane (2 pts)
A Walker _ 2 Canes (3 pts)
Assistance from others (4 pts)
Cannot Walk at all (5 pts)
8. Do you have difficulty controlling
your bowel and bladder function beyond
episodes of diarrhea _ constipation?
* must provide value
Never (1 pts)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Requires Catheterization (5 pts)
III. Pain (5-point scale)
9. Overall, on average, how much
back_neck pain have you had in the past
4 weeks?
* must provide value
None (1 pts)
Very Mild (2 pts)
Mild (3 pts)
Moderate (4 pts)
Severe (5 pts)
10. When you are in your most comfortable
position, do you still experience back _ neck
pain (limiting your sleep)?
* must provide value
Never (1 pts)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Very Often (5 pts)
11. How much has your pain limited
your mobility (sitting, standing,
walking)?
* must provide value
Never (1 pts)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Constantly (5 pts)
12. How confident do you feel about yourur
ability to manage your pain on your own?
* must provide value
Not confident at all (1 pts)
Minimally Confident (2 pts)
Moderately confident (3 pts)
Mostly confident (4 pts)
Completely confident (5 pts)
IV. Mental Health (5-point scale)
13. Have you felt depressed over the
past 4 weeks?
* must provide value
Never (1 pts)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Very Often (5 pts)
14. Do you feel anxiety about your
Health related to your spine?
* must provide value
Never (1 pts)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Very Often (5 pts)
15. Do you have a lot of energy ?
* must provide value
Never (1 pts)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Very Often (5 pts)
16. When I feel pain, it is awful and I feel it
overwhelms me
* must provide value
Never (1 pts)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Very Often (5 pts)
V. Social Function (5-point scale)
17. Does your spine influence your ability to
concentrate on conversations, reading and
television?
* must provide value
Never (1 pt)
Rarely (2 pts)
Sometimes(3 pts)
Often (4 pts)
Very Often (5 pts)
18. Do you feel that your spine condition
impairs_compromises your personal
relationships?
* must provide value
Never (1 pt)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Very Often (5 pts)
19. Are you comfortable meeting new people?
* must provide value
Never (1 pts)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Very Often (5 pt)
20. Do you leave the house for social functions?
* must provide value
Never (1 pts)
Rarely (2 pts)
Sometimes (3 pts)
Often (4 pts)
Very Often (5 pts)
VI. Post Therapy Questions
21. Are you satisfied with the results
of your spine tumor management?
Very Satisfied (1 pts)
Somewhat Satisfied (2 pts)
Neither Satisfied nor Dissatisfied (3 pts)
Somewhat dissatisfied (4 pts)
Very dissatisfied (5 pt)
22. Would you choose the same
management of your spine tumor
again?
Definitely yes (1 pt)
Probably yes (2 pts)
Not sure (3 pts)
Probably not (4 pts)
Definitely not (5 pts)
23. How has treatment of your spine
changed your physical function and
ability to pursue activities of daily
living?
Much Better (1 pt)
Somewhat Better (2 pts)
No change (3 pts)
Somewhat worse (4 pts)
Much worse (5 pts)
24. How has treatment of your spine
affected your spinal cord and_or
nerve function?
Much Better (1 pt)
Somewhat Better(2 pts)
No change (3 pts)
Somewhat worse (4 pts)
Much worse (5 pts)
25. How has your treatment affected your
overall pain from your spine?
Much Better (1 pt)
Somewhat Better (2 pts)
No change (3 pts)
Somewhat worse (4 pts)
Much worse (5 pts)
26. How has treatment of your spine changed
your depression and anxiety?
Much Better (1 pt)
Somewhat Better(2 pts)
No change (3 pts)
Somewhat worse (4 pts)
Much worse (5 pts)
27. How has treatment of your spine changed
your ability to function socially?
Much Better (1 pt)
Somewhat Better (2 pts)
No Change (3 pts)
Somewhat worse (4 pts)
Much worse (5 pts)
Submit
Save & Return Later