Neck Pain Assessment

Is the pain localized, or does it radiate to other areas (e.g., shoulders or arms)?

The pain is localized in my neck only.

The pain radiates to my shoulders.

The pain radiates to my arms or down to my hands.

Other

Please select an option before proceeding.

How would you describe the pain? (Sharp, Dull, Stiffness, Burning)

Sharp pain that worsens with movement.

Dull, aching discomfort that is constant or intermittent.

Stiffness or tightness, especially in the morning or after prolonged sitting.

Other

When do you experience the pain? (Morning, After prolonged sitting, During physical activity, Constantly)

In the morning, especially after waking up.

After prolonged sitting or working at a desk.

Constantly, regardless of time or activity.

Other

Do you experience headaches along with the neck pain? (Yes/No)

Yes

Does the pain worsen with neck movements? (Yes/No)

Yes

How long have you been experiencing this pain?

Less than a week

1-4 weeks

Over a month

Other

How would you rate your pain on a scale of 1-10?

Please select an option before proceeding.

Have you taken any medications or treatments for this pain?

Yes

Is this pain the first time you’ve experienced it, or have you had similar pain before?

Yes, this is the first time I’m experiencing this type of pain.

No, I’ve had this type of pain before, but it went away after a while.

No, I’ve had similar pain before, and it has been recurring.

Have you ever been involved in a road traffic accident (car, bike, or pedestrian)?

Yes, I’ve been in a road traffic accident before and sustained injuries.

Yes, but I did not experience significant injuries at the time.

No, I’ve never been in a road traffic accident.

Have you ever had any fractures or discitys in your body, particularly around the affected area?

Yes, I have had a fracture or discity in the area experiencing pain.

Yes, I’ve had a fracture or discity in another area of my body.

No, I’ve never had any fractures or discitys.

Have you undergone any surgeries in the past, especially related to the area experiencing pain?

Yes, I’ve had surgery in the affected area (e.g., hip, shoulder, back).

Yes, I’ve had surgeries elsewhere in my body but not in the affected area.

No, I have never had any surgeries.

Do you have any other medical conditions that might be related to the pain, such as arthritis, diabetes, or autoimmune disorders?

Yes, I have a medical condition (e.g., arthritis, diabetes, fibromyalgia) that may be related to the pain.

No, I don’t have any known medical conditions related to the pain.

I’m not sure, but I’ve been diagnosed with other health issues.

Personal Details

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Last Name

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Body Type

Age

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Neck Pain Assessment

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