stcacupuncture.com - Functional Rating Index

Functional Rating Index

For use with Neck and/or Back Problems only
In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities.

For each item below, please circle the number which most closely describes your condition right now.
1. Pain Intensity

No painMild painModerate painSevere painWorst possible pain
2. Sleeping

Can do all activitiesCan do most activitiesCan do some activitiesCan do a few activitiesCannot do any activities
3. Personal Care (washing, dressing, etc.)

No pain; no restrictionsMild disturbed sleepModerately disturbed sleepGreatly disturbed sleepTotally disturbed sleep
4. Travel (driving, etc.)

No pain on long tripsMild pain on long tripsModerate pain on long tripsModerate pain on short tripsSevere pain on short trips
5. Work

Can do usual work plus unlimited extra workCan do usual work; no extra workCan do 50% of usual workCan do 25% of usual workCannot work
6. Recreation

Can do all activitiesCan do most activitiesCan do some activitiesCan do a few activitiesCannot do any activities
7. Frequency of pain

No painOccasional pain; 25% of the dayIntermittent pain; 50% of the dayFrequent pain; 75% of the dayConstant pain; 100% of the day
8. Lifting

No pain with heavy weightIncreased pain with heavy weightIncreased pain with moderate weightIncreased pain with light weightIncreased pain with any weight
9. Walking

No pain; any distanceIncreased pain after 1 mileIncreased pain after 1/2 mileIncreased pain after 1/4 mileIncreased pain with all walking
10. Standing

No pain after several hoursIncreased pain after several hoursIncreased pain after 1 hourIncreased pain after 1/2 hourIncreased pain any standing
Name
ID #
Plan ID
Total Score
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: