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 your everyday activities. For each item below, please choose the one which most closely describes your condition right now.

Please review the below listed symptoms and conditions and indicate those that are current health problems of a family member by the designation C under his or her column. The designation P should be used to indicate a past problem. Leave blank those spaces that do not apply.