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Neck Form

The safety of our employees and their family, our patients, are paramount above all else. As we learn more about the novel coronavirus and the disease it cases (COVID-19), we all have to do our part to limit its spread. We reply on guidance from the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and local health officials to guide our health and safety precautions as we continue to operate as an essential business that’s part of the nation’s critical infrastructure. 

 
To that aim, Water & Sports Physical Therapy has implemented enhanced screening of all employees and patients who come to a WSPT clinic. Your honest participation in this process is critical to maintaining everyone’s well being during this time.
Please answer the questions listed before coming in for your appointment.

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NECK DISABILITY INDEX

THIS QUESTIONNARE IS DESIGNED TO HELP US BETTER UNDERSTAND HOW YOUR NECK PAIN AFFECTS YOUR ABILITY TO MANAGE EVERYDAY-LIFE ACTIVITIES. PELASE MARK IN EACH SECTION THE ONE BOX THAT APPLIES TO YOU. ALTHOUGH YOU MAY CONSIDER THAT TWO OF THE STATEMENTS IN ANY ONE SECTION RELATE TO YOU, PLEASE MARK THE BOX THAT MOST CLOSELY DESCRIBES YOUR PRESENT-DAY SITUATION.

SECTION 1 – PAIN INTENSITY
SECTION 2 – PERSONAL CARE
SECTION 3 – LIFTING
SECTION 4 – WORK
SECTION 5 – HEADACHES
SECTION 6 - CONCENTRATION
SECTION 7 - SLEEPING
SECTION 8 - DRIVING
SECTION 9 - READING
SECTION 10 - RECREATION
Patient Name*
MM slash DD slash YYYY