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Returning Patient Inquiries: 609-912-1500

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Dr. Antonacci
Drs. ABC
Testimonials
What is ASC?
Before & After
- After Scoliosis Surgery
FAQs
Videos
For New Patients
Locations
Awards
Forms
Scoliosis
News

Dr. Antonacci
Drs. ABC
Testimonials
What is ASC?
Before & After
- After Scoliosis Surgery
FAQs
Videos
For New Patients
Locations
Awards
Forms
Scoliosis
News

SRS-22r Patient Questionnaire

Please fill out the form below to submit your health informaiton

SRS-22r Patient Questionnaire

This form requires your MRN number, provided through the Institute for Spine & Scoliosis office. Please contact us for an updated link to this form.

Today’s Date

Patient Name

First Name *

Middle Initial

Last Name *

Patient's Sex *

Questions

1) Which one of the following best describes the amount of pain you have experienced during the past 6 months?

None

Mild

Moderate

Moderate to severe

Severe

2) Which one of the following best describes the amount of pain you have experienced over the last month?

None

Mild

Moderate

Moderate to severe

Severe

3) 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

4) If you had to spend the rest of your life with your back shape as it is right now, how would you feel about it?

Very happy

Somewhat happy

Neither happy nor unhappy

Somewhat unhappy

Very unhappy

5) What is your current level of activity?

Bedridden

Primarily no activity

Light labor and light sports

Moderate labor and moderate sports

Full activities without restriction

6) How do you look in clothes?

Very good

Good

Fair

Bad

Very bad

7) In the past 6 months have you felt so down in the dumps that nothing could cheer you up?

Very often

Often

Sometimes

Rarely

Never

8) Do you experience back pain when at rest?

Very often

Often

Sometimes

Rarely

Never

9) What is your current level of work/school activity?

100% normal

75% normal

50% normal

25% normal

0% normal

10) 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

Poor

Very Poor

11) Which one of the following best describes your pain medication use for back pain?

None

Non-narcotics weekly or less (e.g., aspirin, Tylenol, Ibuprofen)

Non-narcotics daily

Narcotics weekly or less (e.g. Tylenol III, Lorcet, Percocet)

Narcotics daily

12) Does your back limit your ability to do things around the house?

Never

Rarely

Sometimes

Often

Very Often

13) Have you felt calm and peaceful during 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

14) Do you feel that your back condition affects your personal relationships?

None

Slightly

Mildly

Moderately

Severely

15) Are you and/or your family experiencing financial difficulties because of your back?

Severely

Moderately

Mildly

Slightly

None

16) In the past 6 months have you felt down hearted and blue?

Never

Rarely

Sometimes

Often

Very often

17) In the last 3 months have you taken any days off of work, including household work, or school because of back pain?

0 days

1 day

2 days

3 days

4 or more days

18) Does your back condition limit your going out with friends/family?

Never

Rarely

Sometimes

Often

Very often

19) Do you feel attractive with your current back condition?

Yes, very

Yes, somewhat

Neither attractive nor unattractive

No, not very much

No, not at all

20) 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

21) Are you satisfied with the results of your back management?

Very satisfied

Satisfied

Neither satisfied nor unsatisfied

Unsatisfied

Very unsatisfied

22) Would you have the same management again if you had the same condition?

Definitely yes

Probably yes

Not sure

Probably not

Definitely not

23) I felt angry when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

24) I had trouble doing schoolwork when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

25) I had trouble sleeping when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

26) It was hard for me to pay attention when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

27) It was hard for me to run when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

27) It was hard for me to walk one block when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

28) It was hard to have fun when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

29) It was hard to stay standing when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

30) I hurt a lot

Never

Almost Never

Sometimes

Often

Almost Always

31) I hurt all over my body

Never

Almost Never

Sometimes

Often

Almost Always

32) I missed school when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

33) It was hard for me to remember things when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

34) It was hard to get along with other people when I had pain

Never

Almost Never

Sometimes

Often

Almost Always

35) It was hard for me to be away from home because I had pain

Never

Almost Never

Sometimes

Often

Almost Always

35) It was hard to have fun with friends because I was in pain

Never

Almost Never

Sometimes

Often

Almost Always

36) I needed help walking when I was in pain

Never

Almost Never

Sometimes

Often

Almost Always

37) I walked carefully when I was in pain

Never

Almost Never

Sometimes

Often

Almost Always

38) I had so much pain I had to stop what I was doing

Never

Almost Never

Sometimes

Often

Almost Always

40) My pain was so bad that I needed to take medicine to treat it

Never

Almost Never

Sometimes

Often

Almost Always

41) It was hard to do things with my family because I had pain

Never

Almost Never

Sometimes

Often

Almost Always

Thank you for completing this questionnaire. Please comment if you wish.

Please provide the name of the person filling out this form (you) and your email address below

NAME of Person Filling Out Form *

EMAIL of Person Filling Out Form *

If you are human, leave this field blank.

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