Prior Lake Spine - Functional Rating Index

Functional Rating Index
Name*

First NameLast Name
Date

MonthDayYear
Date
Where are you currently experiencing symptoms (ie neck, back, shoulder, hip, etc)?*
Please include descriptions like Right, Left, Upper, Middle, Lower, etc.
How would you describe your symptoms? (please check all that apply)*

AcheSharpShootingStabbingBurningNumbnessTinglingOther
For neck, back or other musculoskeletal symptoms: Please select the number which most closely describes your condition right now.
Section 1 – Pain Intensity*

0) No Pain1) Mild pain2) Moderate pain3) Severe pain4) Worst possible pain
Section 2 - Sleeping*

0) Perfect sleep1) Mildly disturbed sleep2) Moderately disturbed sleep3) Greatly disturbed sleep4) Totally disturbed sleep
Section 3 – Personal Care (Washing, Dressing, etc.)*

0) No pain; No restrictions1) Mild pain; No restrictions2) Moderate pain; Need to go slowly3) Moderate pain; Need some assistance4) Severe pain; Need 100% assistance
Section 4 – Traveling (Driving, etc.)*

0) No pain on long trips1) Mild pain on long trips2) Moderate pain on long trips3) Moderate pain on short trips4) Severe pain on short trips
Section 5 – Work*

0) Can do usual work plus unlimited extra work1) Can do usual work but no extra work2) Can do 50% of usual work3) Can do 25% of usual work4) Cannot work
Section 6 – Recreation*

0) Can do all activities1) Can do most activities2) Can do some activities3) Can do a few activities4) Cannot do any activities
Section 7 – Frequency of Pain*

0) No pain1) Occasional pain; 25% of the day2) Intermittent pain; 50% of the day3) Frequent pain; 75% of the day4) Constant pain; 100% of the day
Section 8 – Lifting*

0) No pain with heavy weight1) Increased pain with heavy weight2) Increased pain with moderate weight3) Increased pain with light weight4) Increased pain with any weight
Section 9 – Walking*

0) No pain; Any distance1) Increased pain after 1.0 mile2) Increased pain after ½ mile3) Increased pain after ¼ mile4) Increased pain with any weight
Section 10 – Standing*

0) No pain after several hours1) Increased pain after several hours2) Increased pain after 1 hour3) Increased pain after ½ hour4) Increased pain with any standing
Should be Empty: