Pain Disability Questionnaire

Legal Name*
First Name Last Name
Patient ID#*
Date
MM slash DD slash YYYY
Clinic Location*
Does your pain interfere with your normal work inside and outside the home?
Does your pain interfere with personal care (ex: washing, dressing, etc.)?
Does your pain interfere with your traveling?
Does your pain affect your ability to sit or stand?
Does your pain affect your ability to lift overhead, grasp objects, or reach for things?
Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat?
Does your pain affect your ability to walk or run?
Has your income declined since your pain began?
Do you take pain medication every day to control your pain?
Does your pain force you to see doctors much more than before your pain began?
Does your pain interfere with your ability to see the people who are important to you as much as you would like?
Does your pain interfere with recreational activities and hobbies that are important to you?
Do you need the help of your family and friends to complete everyday tasks (including both work outside the home and housework) because of your pain?
Do you now feel more depressed, tense, or anxious than before your pain began?
Are there emotional problems caused by your pain that interfere with your family, social, and or work activities?
PEG Assessment
What number best describes your pain on average in the past week?
What number best describes how, during the past week, pain has interfered with your enjoyment of life?
What number best describes how, during the past week, pain has interfered with your general activity?
Verify*
- I acknowledge that this information is true and correct.

How can Tuck Chiropractic help you?

Whether you just want a better health lifestyle or you need relief from intense or chronic pain, we can help.

I Want A Better Lifestyle I'm In Pain Right Now

Accessibility by WAH

Call Us Locations

Pain Disability Questionnaire

PEG Assessment

How can Tuck Chiropractic help you?