Chiropractor - Davis Clinic of Chiropractic

1585 Santa Barbara Blvd, Suite A
The Villages, FL 32159

(352) 430-2121

Neck Pain Self-Test

This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage everyday life. Please answer every section and mark only ONE box that applies to you. We realize that you may consider that two of the same statements in any one section relate to you, but please just mark the box that most closely describes your problem.

Neck Pain Diagnostic Self Test


SECTION 1 - PAIN INTENSITY

SECTION 2 - PERSONAL CARE (Washing, Dressing, etc.)

Section 3 - LIFTING

SECTION 4 - READING

SECTION 5 HEADACHES

SECTION 6 - CONCENTRATION

SECTION 7 - WORK

SECTION 8 - DRIVING

SECTION 9 - SLEEPING

SECTION 10 - RECREATION

Learn More About Our
Non-Surgical Treatments


Contact


Davis Clinic of Chiropractic
1585 Santa Barbara Blvd, Suite A
The Villages, Fl 32159

Phone: (352) 430-2121