SRS 24 Patient Questionnaire - Scoliosis Research Society

srs.org

SRS 24 Patient Questionnaire - Scoliosis Research Society

SRS-24Scoliosis Research Society’s Scoliosis Patient QuestionnairePatient Name: __________________________Medical Record #: _______________________Surgery date: ___________________________Age: ___________ Date: ____________SS#: _____________________________Follow-up: ________________________We are carefully evaluating the condition of your back. Please circle the best answer to eachquestion unless otherwise indicated.1. On a scale of 1 to 9, with 1 meaning “no pain” and 9 meaning “severe pain”, Indicate thedegree of pain you experience regularly1 2 3 4 5 6 7 8 92. Using the same scale, indicate the most severe degree of pain you have experienced over thelast month.1 2 3 4 5 6 7 8 93. If you had to spend the rest of your life with your back as it is right now, how would you feelabout it?Very happySomewhat happyNeither happy nor unhappySomewhat unhappyVery unhappy4. What is your current level of activity?Bedridden/WheelchairPrimarily no activityLight labor, such as household choresModerate manual labor and moderate sports, such as walking and bikingFull activities without restriction(Continued on Next Page)1


SRS-245. How do you look in clothes?Very goodGoodFairBadVery bad6. Do you experience back pain when at rest?Very oftenOftenSometimesRarelyNever7. What is your current level of work/school activity?100% normal75% normal50% normal25% normal0% normal8. What medications, if any, are you currently taking for your back? (circle all that apply)NoneNon-steroidals (i.e. Motrin)Steroids (cortisone)Muscle Relaxants (Valium)Narcotics (Morphine)9. Does your back limit your ability to do things around the house?YesNo10. Have you taken any sick days from work/school due to back pain?YesNo(Continued on Next Page)2


SRS-2411. Do you feel your condition affects your personal relationships?YesNo12. Are you and/or your family experiencing financial difficulties because of your back?None Some A lot13. Do you go out more or less than your friends?More Same Less14. Do you feel attractive?Yes, veryYes, somewhatNeither attractive nor unattractiveNo, not very muchNo, not at all15. On a scale of 1 to 9, with one being very low and 9 being extremely high how would yourate your self-image?1 2 3 4 5 6 7 8 916. Has your back treatment changed your function or daily activity?Increased Not changed Decreased17. Has your back treatment changed your ability to enjoy sports/hobbies?Increased Not changed Decreased18. Has your treatment ___________ your back pain?Increased Not changed Decreased(Continued on Next Page)3


SRS-2419. Has your treatment changed your confidence in personal relationships with others?Increased Not changed Decreased20. Has your treatment changed the way others view you?Much betterBetterSameWorseMuch worse21. Has your treatment changed your self-image?Increased Not changed Decreased22. Are you satisfied with the results of your back treatment?Extremely satisfiedSomewhat satisfiedNeither satisfied nor dissatisfiedSomewhat dissatisfiedExtremely dissatisfied23. Compared to before your treatment, how do you feel you now look?Much betterBetterSameWorseMuch worse24. Would you have the same treatment again if you had the same condition?Definitely yesProbably yesNot sureProbably notDefinitely notThank you for completing this questionnaire.End4


SRS-24Scoliosis Research Society’s Scoliosis Patient Questionnaire: Score SheetName: ____________________________________________________________Diagnosis: _________________________________________________________Date: ________________________ Interval _____________________________Domain Score # QuestionPt/Possible (Max) Answered(Poss) Meana a` b a÷bPain _____ _____ _____ _____ _____ _____ _____ ___/___(35) ___ (7) ___.__1* 2 3 6 8 11 18General self-image _____ _____ _____ ___/___(15) ___ (3) ___.__5 14 15Self-image after surgery _____ _____ _____ ___/___(15) ___ (3) ___.__19 20 21Function after surgery _____ _____ ___/___(10) ___ (2) ___.__16 17General function _____ _____ _____ ___/___(15) ___ (3) ___.__7 12 13Function-activity _____ _____ _____ ___/___(15) ___ (3) ___.__4 9 10Satisfaction with surgery _____ _____ _____ ___/___(15) ___ (3) ___.__22 23 24* Question numberTOTAL ___/___(120) ___ (24) ___.__Mean Scorea/a` X 100= ( %) 5 Best100% Best 1 Worst20% Worst5

More magazines by this user
Similar magazines