SRS 22 SRS 22This SRS 22 form is used to better understand how Scoliosis affects you - please fill this form out only if you have been directed to do so by your doctor.Part 1About YouPrefixMr.Mrs.Ms.Mx.MissDr.Prof.First NameMiddle NameLast NameEmail AddressPart 2How Scoliosis affects youFor each of the following questions, please select the option which best describes the way you feel.Which one of the following best describes the amount of pain you have experienced during the past 6 months?NoneMildModerateModerate to SevereSevereWhich one of the following best describes the amount of pain you have experienced over the last month?NoneMildModerateModerate to SevereSevereDuring the past 6 months have you been a very nervous person?None of timeA little of the timeSome of the timeMost of the timeAll of the timeDuring the past 6 months have you been a very nervous person?None of timeA little of the timeSome of the timeMost of the timeAll of the timeIf you had to spend the rest of your life with your back shape as it is right now, how would you feel about it?Very happySomewhat happyNeither happy nor unhappyUnhappyVery unhappyWhat is your current level of activity?BedriddenPrimarily no activityLight labor and light sports Moderate labor and moderate sportsFull activity with no restrictions How do you look in clothes? Very goodGoodFairBadVery badIn the past 6 months have you felt so down in the dumps that nothing could cheer you up?Very oftenOftenSometimesRarelyNeverDo you experience back pain when at rest?Very oftenOftenSometimesRarelyNeverWhat is your current level of work/school activity?100% normal75% normal50% normal25% normal0% normalWhich of the following best describes the appearance of your trunk; defined as the human body except for the head and extremities?Very goodGoodFairPoorVery poorWhich one of the following best describes your pain medication use for back pain?NoneNon-narcotics weekly or less (e.g., aspirin, Tylenol, Ibuprofen) Non-narcotics daily Narcotics weekly or less (e.g. Endone, Oxycontin orally or, Norspan , Durogesic patches) Narcotics daily Does your back limit your ability to do things around the house?NeverRarelySomtimes OftenVery oftenHave you felt calm and peaceful during the past 6 months?All of the timeMost of the time Some of the time A little of the time None of the time Do you feel that your back condition affects your personal relationships?NoneSlightly Mildly Moderately SeverelyAre you and/or your family experiencing financial difficulties because of your back?SeverelyModeratelyMildly SlightlyNoneIn the past 6 months have you felt down hearted and blue?NeverRarelySometimesOftenVery oftenIn the last 3 months have you taken any days off of work, including household work, or school because of back pain?0 days1 day2 days3 days4 or more daysDoes your back condition limit your going out with friends/family?NeverRarelySometimesOftenVery oftenDo you feel attractive with your current back condition?Yes, veryYes, somewhatNeither attractive nor unacttractive No, not very muchNo, not at allHave you been a happy person during the past 6 months?None of the timeA little of the timeSome of the time Most of the time All of the time Are you satisfied with the results of your back management so far?Very satisfiedSatisfied Neither satisfied nor unsatisfiedUnsatisfiedVery unsatisfiedWould you have the same management again if you had the same condition?Definitely yes Probably yes Not sure Probably not Definitely not Send MessagePlease do not fill in this field.
