Patient Questionnaire

Thankyou for completing this questionnaire. Please comment by email if you wish. Click here to contact Simone Icough of ScoliosisNutty

This questionnaire is thanks to the American Academy of Orthopaedic Surgeons, the results provided here will be sent to your email address and also to the webmistress of ScoliosisNutty so that she can send these results to the American Academy of Orthopaedic Surgeons. If you do not wish these results to be used for any purpose then please email me.

Your NickName
Your Email Address
What Type Of Scoliosis Do You Have?

On a scale of 1 to 9, with 1 meaning "no pain" and 9 meaning "severe pain", indicate the degree of pain you have experienced during the past 6 months.	1 2 3 4 5 6 7 8 9

Using the same scale, indicate the most severe degree of pain you have experienced over the last month.	1 2 3 4 5 6 7 8 9

During the past 6 months have you been a very nervous person?	None of the time A little of the time Some of the time Most of the time All of the time

If you had to spend the rest of your life with your back as it is right now, how would you feel about it?	Very happy Somewhat happy Neither happy nor unhappy Somewhat unhappy Very unhappy

What is your current level of activity?	Bedridden/Wheelchair Primarily no activity Light labour, such as household chores Moderate manual labour and moderate sports, such as walking and biking Full activities without restriction

How do you look in clothes?	Very good Good Fair Bad Very bad

In the past 6 months have you felt sp down in the dumps that nothing could cheer you up?	Very often Often Sometimes Rarely Never

Do you experience back pain when at rest?	Very often Often Sometimes Rarely Never

What is your current level of work/school activity	100% normal 75% normal 50% normal 25% normal 0% normal

Which of the following best describes the appearance of your trunk, defined as the human body except for the head and extremities.	Very good Good Fair Bad Very bad

Which of the following best describes your medication usage for your back?	None Non narcotics weekly or less (eg aspirin, Tylenol, Ibuprofen) non narcotics daily Narcotics weekly or less (eg Tylenol, Lorocet, Percocet) Other Medication Usage (Daily, Weekly etc)

Does your back limit your ability to do things around the house?	Never Rarely Sometimes Often Very often

Have you felt calm and peaceful in the past 6 months?	All of the time Most of the time Some of the time A little of the time None of the time

Do you feel that your condition affects your personal relationships?	None Slightly Mildly Moderately Severely

Are you/or your family experiencing financial difficulties because of your back?	Severely Moderately Mildly Slightly None

In the past 6 months have you felt down hearted and blue?	Never Rarely Sometimes Often Very often

In the last 3 months have you taken any sick days from work/school due to back pain and if so how many?	0 1 2 3 4 or more

Do you go out more or less than your friends?	Much more More Same Less Much less

Do you feel attractive?	Yes, very Yes, somewhat Neither attractive or unattractive No, not very much No, not at all

Have you been a happy person during the past 6 months?	None of the time A little of the time Some of the time Most of the time All of the time

Are you satisfied with the results of your back management?	Extremely satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Extremely satisfied

Would you have the same management again if you had the same condition?	Definitely yes Probably yes Not sure Probably not Definitely not

Patient Questionnaire

Patient Questionnaire