Patient: Susan Martin (ID# 563971821)

Date: February 6, 2004

Examined by: David L. Johnson, D.C.

This self-administered subjective test quantifies the degree of functional impairment of individuals with neck pain. Susan scored a 46%, or moderate disability in the ability to perform the normal activities of daily living.

D) The pain is fairly severe at the moment.

B) I can look after myself normally, but it causes extra pain.

D) Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned.

D) I cannot read as much as I want because of moderate pain in my neck.

E) I have severe headaches which come frequently.

C) I have a fair degree of difficulty in concentrating when I want to.

C) I can do most of my usual work, but no more.

B) I can drive my car as long as I want with slight pain in my neck.

C) My sleep is mildly disturbed (1-2 hours sleepless).

C) I am able to engage in most, but not all of my usual recreation activities because of pain in my neck.