Questionnaires For Evaluation

← Back to Main Page

ConchyMan's Tele-Rehabilitation

Professional Online Physiotherapy Consultation & Rehabilitation Services

📋 SPADI Assessment Form — Click to Expand

SPADI Assessment Form

Patient Information

Patient Name Age Sex MaleFemaleOther Chief Complaint Consultation ID Date

Pain Section

Question	Score (0-10)
Pain at its worst
Pain when lying on involved side
Pain reaching high shelf
Pain touching back of neck
Pain pushing with involved arm

Disability Section

Question	Score (0-10)
Washing Hair
Washing Back
Putting on Undershirt
Putting on Shirt
Putting on Pants
Placing Object on High Shelf
Carrying Heavy Object
Removing Object from Back Pocket

📋 Quick DASH Assessment Form — Click to Expand

QuickDASH Assessment Form

Patient Information

Patient Name Age Sex MaleFemaleOther Chief Complaint Consultation ID Date

QuickDASH Questionnaire

Rate each activity: 1=No Difficulty, 2=Mild, 3=Moderate, 4=Severe, 5=Unable

Question	Score (1-5)
Open a tight or new jar
Do heavy household chores
Carry a shopping bag or briefcase
Wash your back
Use a knife to cut food
Recreational activities involving force through arm
Extent arm problem interferes with social activities
Extent arm problem limits work or daily activities
Arm, shoulder or hand pain
Tingling in arm, shoulder or hand
Difficulty sleeping because of arm problem

📋 Neck Disability Index (NDI) Assessment Form — Click to Expand

Neck Disability Index (NDI)

Patient Information

Patient Name Age Sex MaleFemaleOther Chief Complaint Consultation ID Assessment Date

NDI Assessment

Section	Score (0-5)
Pain Intensity	Select012345
Personal Care	Select012345
Lifting	Select012345
Reading	Select012345
Headaches	Select012345
Concentration	Select012345
Work	Select012345
Driving	Select012345
Sleeping	Select012345
Recreation	Select012345

Result will appear here.

📋 LBA - Oswestry Disability Index (ODI) Assessment Form — Click to Expand

Oswestry LBA Disability Questionnaire (ODI)

Report ID:

Patient Information

Patient Name

Age

SexMaleFemaleOther

Chief Complaint

Consultation ID

Assessment Date

Therapist Information

Therapist Name

Registration Number

ODI Assessment

Section	Score (0-5)
Pain Intensity	Select012345
Personal Care	Select012345
Lifting	Select012345
Walking	Select012345
Sitting	Select012345
Standing	Select012345
Sleeping	Select012345
Social Life	Select012345
Travelling	Select012345
Employment / Homemaking	Select012345

Result will appear here.

📋 Oxford Knee Score (OKS) Assessment Form — Click to Expand

Oxford Knee Score (OKS)

Report ID:

Patient Information

Patient Name

Age

SexMaleFemaleOther

Chief Complaint

Consultation ID

Assessment Date

Oxford Knee Score Assessment

Rate each question: 0=Severe, 1=Moderate, 2=Mild, 3=Very Mild, 4=No problem

Question	Score (0-4)
How would you describe the pain in your knee?	Select0 - Severe1 - Moderate2 - Mild3 - Very Mild4 - None
Difficulty with washing and drying yourself?	Select0 - Impossible1 - Severe difficulty2 - Moderate difficulty3 - Mild difficulty4 - No difficulty
Difficulty getting in/out of a car or bus?	Select0 - Impossible1 - Severe difficulty2 - Moderate difficulty3 - Mild difficulty4 - No difficulty
How long can you walk before pain becomes severe?	Select0 - Less than 5 min1 - 5-15 min2 - 15-30 min3 - 30-60 min4 - Over 60 min
Pain while sitting or lying in bed?	Select0 - Every night1 - Most nights2 - Some nights3 - Rarely4 - Never
Has knee problem interfered with your work?	Select0 - Totally1 - Greatly2 - Moderately3 - Slightly4 - Not at all
Difficulty climbing stairs?	Select0 - Impossible1 - Severe difficulty2 - Moderate difficulty3 - Mild difficulty4 - No difficulty
Difficulty kneeling down and getting back up?	Select0 - Impossible1 - Severe difficulty2 - Moderate difficulty3 - Mild difficulty4 - No difficulty
Pain in knee while walking on flat surface?	Select0 - All the time1 - Most days2 - Some days3 - Rarely4 - Never
Has knee problem affected your social activities?	Select0 - Totally1 - Greatly2 - Moderately3 - Slightly4 - Not at all
Can you do your own shopping?	Select0 - Impossible1 - Severe difficulty2 - Moderate difficulty3 - Mild difficulty4 - No difficulty
Difficulty going down stairs?	Select0 - Impossible1 - Severe difficulty2 - Moderate difficulty3 - Mild difficulty4 - No difficulty

Result will appear here.

📋 Foot & Ankle Functional Assessment Form — Click to Expand

ConchyMan's Tele-Rehabilitation

Foot & Ankle Functional Assessment

Report ID

Assessment Date

Patient Name

Age

SexMaleFemaleOther

Consultation ID

Chief Complaint

Therapist Name

Assessment Area	Score (0-4)

Assessment Result

Total Score: -

Percentage: -

Interpretation: -

Outcome Measure: -

Scoring Guide

4 = No Difficulty  |  3 = Mild Difficulty  |  2 = Moderate Difficulty  |  1 = Severe Difficulty  |  0 = Unable

ConchyMan's Tele-Rehabilitation Services

Evidence-Based Online Physiotherapy Care

← Back to Main Page