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Care Connections Tool

Care Connections Tool - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires


NAME DATE
TIME AM/PM
r Initial Visit r Discharge Visit
PATIENT WORKSHEET 1 © 2010 Therapeutic Associates, Inc. (Revised: 11/16/10) FORM C004
PART II: Choose the one answer that best describes your condition in the sections
designated by your therapist.
n A. UPPER EXTREMITY
CARRYING
r I can carry heavy loads without increased symptoms.
r I can carry heavy loads with some increased symptoms.
r I cannot carry heavy loads overhead, but I can manage if they are
positioned close to my trunk.
r I cannot carry heavy loads, but I can manage light to medium
loads if they are positioned close to my trunk.
r I can carry very light weights with some increased symptoms.
r I cannot lift or carry anything at all.
DRESSING
r I can put on a shirt or blouse without symptoms.
r I can put on a shirt or blouse with some increased symptoms.
r It is painful to put on a shirt or blouse and I am slow and careful.
r I need some help but I manage most of my shirt or blouse
dressing.
r I need help in most aspects of putting on my shirt or blouse.
r I cannot put on a shirt or blouse at all.
REACHING
r I can reach to a high shelf to place an empty cup without
increased symptoms.
r I can reach to a high shelf to place an empty cup with some
increased symptoms.
r I can reach to a high shelf to place an empty cup with a moderate
increase in symptoms.
r I cannot reach to a high shelf to place an empty cup, but I can
reach up to a lower shelf without increased symptoms.
r I cannot reach up to a lower shelf without increased symptoms,
but I can reach counter height to place an empty cup.
r I cannot reach my hand above waist level without increased
symptoms.
n B. LOWER EXTREMITY
STAIRS
r I can walk stairs comfortably without a rail.
r I can walk stairs comfortably, but with a crutch, cane, or rail.
r I can walk more than 1 flight of stairs, but with increased
symptoms.
r I can walk less than 1 flight of stairs.
r I can manage only a single step or curb.
r I am unable to manage even a step or curb.
UNEVEN GROUND
r I can walk normally on uneven ground without loss of balance or
using a cane or crutches.
r I can walk on uneven ground, but with loss of balance or with the
use of a cane or crutches.
r I have to walk very carefully on uneven ground
without using a cane or crutches.
r I have to walk very carefully on uneven ground even when using a
cane or crutches.
r I have to walk very carefully on uneven ground and require
physical assistance to manage it.
r I am unable to walk on uneven ground.
PATIENT WORKSHEET
FUNCTIONAL INDEX
PART I: Answer all five sections in Part 1. Choose the one answer in each section
that best describes your condition.
WALKING
r Symptoms do not prevent me walking any distance.
r Symptoms prevent me walking more than 1 mile.
r Symptoms prevent me walking more than 1/2 mile.
r Symptoms prevent me walking more than 1/4 mile.
r I can only walk using a stick or crutches.
r I am in bed most of the time and have to crawl to the toilet.
WORK
(Applies to work in home and outside)
r I can do as much work as I want to.
r I can only do my usual work, but no more.
r I can do most of my usual work, but no more.
r I cannot do my usual work.
r I can hardly do any work at all (only light duty).
r I cannot do any work at all.
PERSONAL CARE
(Washing, Dressing, etc.)
r I can manage all personal care without symptoms.
r I can manage all personal care with some
increased symptoms.
r Personal care requires slow, concise movements due to increased
symptoms.
r I need help to manage some personal care.
r I need help to manage all personal care.
r I cannot manage any personal care.
SLEEPING
r I have no trouble sleeping.
r My sleep is mildly disturbed (less than 1 hr. sleepless).
r My sleep is mildly disturbed (1–2 hrs. sleepless).
r My sleep is moderately disturbed (2–3 hrs. sleepless).
r My sleep is greatly disturbed (3–5 hrs. sleepless).
r My sleep is completely disturbed (5–7 hrs. sleepless).
RECREATION/SPORTS
(Indicate Sport if Appropriate _________________________ )
r I am able to engage in all my recreational/sports activities without
increased symptoms.
r I am able to engage in all my recreational/sports activities with
some increased symptoms.
r I am able to engage in most, but not all of my usual recreational/
sports activities because of increased symptoms.
r I am able to engage in a few of my usual recreational/sports
activities because of my increased symptoms.
r I can hardly do any recreational/sports activities because of
increased symptoms.
r I cannot do any recreational/sports activities at all.
ACUITY (Answer on initial visit.)
How many days ago did onset/injury occur? ___________days
PROBLEM AREA (Please check one):
r Upper Extremity (A,D) r Lower Extremity (B,F) r Cervical/Thoracic (C,D) r Lumbar (D,F) r TMJ (C,E)

n E. TMJ
TALKING
r I can talk without any increased symptoms.
r I can talk as long as I want with slight symptoms in my jaws.
r I can talk as long as I want with moderate symptoms in my jaws.
r I cannot talk as long as I want because of moderate symptoms in
my jaws.
r I can hardly talk at all because of severe symptoms in my jaws.
r I cannot talk at all.
EATING
r I can eat whatever I want without symptoms.
r I can eat whatever I want but it gives extra symptoms.
r Symptoms prevent me from eating regular food, but I can manage
if I avoid hard foods.
r Symptoms prevent me from chewing anything other than soft
foods.
r I can chew soft foods occasionally, but primarily adhere to a liquid
diet.
r I cannot chew at all and maintain a liquid diet.
n F. LUMBAR*/LOWER EXTREMITY
STANDING
r I can stand as long as I want without increased symptoms.
r I can stand as long as I want, but it gives me extra symptoms.
r Symptoms prevent me from standing for more than 1 hour.
r Symptoms prevent me from standing for more than 30 minutes.
r Symptoms prevent me from standing for more than 10 minutes.
r Symptoms prevent me from standing at all.
SQUATTING
r I can squat fully without the use of my arms for support.
r I can squat fully, but with symptoms or using my arms for support.
r I can squat 3/4 of my normal depth, but less than fully.
r I can squat 1/2 of my normal depth, but less than 3/4.
r I can squat 1/4 of my normal depth, but less than 1/2.
r I am unable to squat any distance due to symptoms.
SITTING
r I can sit in any chair as long as I like.
r I can only sit in my favorite chair as long as I like.
r My symptoms prevent me sitting more than 1 hour.
r My symptoms prevent me sitting more than 1/2 hour.
r My symptoms prevent me sitting more than 10 minutes.
r My symptoms prevent me from sitting at all.
* Lumbar questions adapted from Oswestry.
n C. CERVICAL/TMJ
CONCENTRATION
r I can concentrate fully when I want to with no difficulty
r I can concentrate fully when I want to with slight difficulty.
r I have a fair degree of difficulty in concentrating when I want to.
r I have a lot of difficulty in concentrating when I want to.
r I have a great deal of difficulty in concentrating when I want to.
r I cannot concentrate at all.
HEADACHES
r I have no headaches at all.
r I have slight headaches which come less than 3 per week.
r I have moderate headaches which come infrequently.
r I have moderate headaches which come 4 or more per week.
r I have severe headaches which come frequently.
r I have headaches almost all of the time.
READING
r I can read as much as I want without increased symptoms.
r I can read as much as I want with slight symptoms.
r I can read as much as I want with moderate symptoms.
r I cannot read as much as I want because of moderate symptoms.
r I can hardly read at all because of severe symptoms.
r I cannot read at all.
n D. LUMBAR*/CERVICAL/UPPER EXTREMITY
DRIVING
r I can drive my car or travel without any extra symptoms.
r I can drive my car or travel as long as I want with slight
symptoms.
r I can drive my car or travel as long as I want with moderate
symptoms.
r I cannot drive my car or travel as long as I want because of
moderate symptoms.
r I can hardly drive at all or travel because of severe symptoms.
r I cannot drive my car or travel at all.
LIFTING
r I can lift heavy weights without extra symptoms.
r I can lift heavy weights but it gives extra symptoms.
r My symptoms prevent me from lifting heavy weights but I manage
if they are conveniently positioned. (e.g. on a table)
r My symptoms prevent me from lifting heavy weights but I manage
light to medium weights if they are conveniently positioned.
r I can lift only very light weights.
r I cannot lift or carry anything at all.
PAIN INDEX
Please indicate the worst your pain has been in the last 24 hours on the scale below
No Pain Worst Pain Imaginable
P L E A S E D O N O T C O M P L E T E T H E F O L L O W I N G S E C T I O N S O N F I R S T V I S I T
GLOBAL RATING OF CHANGE
With respect to the reason you sought treatment, how would you describe yourself now compared to your first treatment at our clinic?
(Circle one)
1. r No lost work time
2. r Return to work without restriction
3. r Return to work with modification
4. r Have not returned to work
5. r Not employed outside the home
Work days lost due to condition: _______________days
I am aware that the information gathered on this form may be used anonymously for research or publication. Please initial: ____________
n WORK STATUS (check most appropriate)
-7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7
Very Much Worse Unchanged Completely Recovered