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Question	Description	Rating
Pain Intensity	NDI #1	TBD
Sleeping	NDI #7	TBD
y	y	TBD
What is your favorite color?	I loke colors	TBD
Neck Pain	General questions	TBD
Admin input 0-10	10	TBD
admin custom	ad	TBD
Personal Care (Washing, Dressing, etc.)	NDI #2 I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but can manage most of my personal care I need help every day in most aspects of self care I do not get dressed, I wash with difficulty and stay in bed	TBD
Lifting	NDI #3 I can lift heavy weights without extra pain I can lift heavy weights but it gives extra pain Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned I can only lift very light weights I cannot lift or carry anything	TBD
Reading	NDI #9 I can read as much as I want to with no pain in my neck I can read as much as I want to with slight pain in my neck I can read as much as I want with moderate pain in my neck I canâ€™t read as much as I want because of moderate pain in my neck I can hardly read at all because of severe pain in my neck I cannot read at all	TBD
Headaches	NDI #5 I have no headaches at all I have slight headaches, which come infrequently I have moderate headaches, which come infrequently I have moderate headaches, which come frequently I have severe headaches, which come frequently I have headaches almost all the time	TBD
Do you have a problem accessing food	n/a	TBD
test axial cs circ	test	TBD
test multiregion Everything good?	test	TBD
Eyes/Vision	Have you had any trouble with your eyes or vision?	TBD
Ears, Nose, Throat	Ears, nose, throat	TBD
Lungs, breathing	Lungs, breathing	TBD
Teeth/Mouth problems	Teeth, mouth	TBD
Atrial Fibrillation	Atrial Firbrilation	TBD
Bleeding Disorder	Bleeding Disorder.	TBD
Heart Failure	Heart Failure	TBD
COPD	Chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis and emphysema, is a long-term lung disease that makes it hard to breathe.	TBD
Pulmonary Embolism	Pulmonary embolism is a blockage in one of the pulmonary arteries in your lungs. In most cases, pulmonary embolism is caused by blood clots that travel to the lungs from deep veins in the legs or, rarely, from veins in other parts of the body (deep vein thrombosis).	TBD
Depression	A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.	TBD
Diabetes	A group of diseases that result in too much sugar in the blood (high blood glucose).	TBD
Blood Clots	A thrombus, colloquially called a blood clot, is the final product of the blood coagulation step in hemostasis.	TBD
Seizures	A seizure, formally known as an epileptic seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with loss of consciousness (tonic-clonic seizure), to shaking movements involving only part of the body with variable levels of consciousness (focal seizure), to a subtle momentary loss of awareness (absence seizure).[3] Most of the time these episodes last less than 2 minutes and it takes some time to return to normal.Loss of bladder control may occur.[	TBD
Stomach Disease	Stomach diseases include gastritis, gastroparesis, Crohn's disease.	TBD
Gout	Gout is a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot, and swollen joint.	TBD
Heart Attack	A myocardial infarction (MI), also known as a heart attack, occurs when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle.[	TBD
Pneumonia	Pneumonia is an inflammatory condition of the lung affecting primarily the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever and difficulty breathing.	TBD
Heart Disease	Disease involving the heart or blood vessels of the heart. It includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack).	TBD
Hepatitis	Hepatitis is inflammation of the liver tissue.	TBD
High Blood Pressure	High blood pressure also known as HBP or Hypertension (HTN or HT), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated.	TBD
High Cholesterol	It is a form of hyperlipidemia, high blood lipids, and hyperlipoproteinemia (elevated levels of lipoproteins in the blood).	TBD
HIV/AIDS	Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV).	TBD
Kidney Disease	Kidney disease, or renal disease, also known as nephropathy, is damage to or disease of a kidney.	TBD
Liver Disease	Liver disease (also called hepatic disease) is a type of damage to or disease of the liver.	TBD
Skin Problems	Skin problems.	TBD
MRSA Infections	Methicillin-resistant Staphylococcus aureus (MRSA) refers to a group of Gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus. MRSA is responsible for several difficult-to-treat infections in humans.	TBD
Rheumatoid Arthritis	Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints.	TBD
Stroke	A stroke is a medical condition in which poor blood flow to the brain results in cell death.	TBD
Dental Problems	Dental problems including teeth our mouth pain as well as cavities and other dental issues.	TBD
Fibromyalgia	Fibromyalgia (FM) is a medical condition characterized by chronic widespread pain and a heightened pain response to pressure.	TBD
Osteoarthritis	Osteoarthritis (OA) is a type of joint disease that results from breakdown of joint cartilage and underlying bone.	TBD
Fever	Fever, also referred to as pyrexia, is defined as having a temperature above the normal range due to an increase in the body's temperature set point.	TBD
Weight Loss	Weight loss, in the context of medicine, health, or physical fitness, refers to a reduction of the total body mass, due to a mean loss of fluid, body fat or adipose tissue or lean mass, namely bone mineral deposits, muscle, tendon, and other connective tissue.	TBD
Concentration	Concentration	TBD
Recreation	Recreation	TBD
Work	NDI #7 Work	TBD
Driving	Driving	TBD
Personal Care (Washing, Dressing, etc.)	ODI I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but can manage most of my personal care I need help every day in most aspects of self care I do not get dressed, I wash with difficulty and stay in bed	TBD
Pain Intensity	Oswestry Disability Index	TBD
Lifting	I can lift heavy weights without extra pain Â… I can lift heavy weights but it gives extra pain Â… Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, i.e. on a table Â… Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned Â… I can lift very light weights Â… I cannot lift or carry anything at all	TBD
Walking	Oswestry: Pain does not prevent me walking any distance Â… Pain prevents me walking more than one mile Â… Pain prevents me walking more than Â½ mile Â… Pain prevents me walking more than Â¼ mile Â… I can only walk using a stick or crutches Â… I am in bed most of the time and have to crawl to the toilet	TBD
Sitting	Oswestry Disability Index: I can sit in any chair as long as I like Â… I can only sit in my favorite chair as long as I like Â… Pain prevents me from sitting more than one hour Â… Pain prevents me from sitting more than Â½ hour Â… Pain prevents me from sitting more than 10 minutes Â… Pain prevents me from sitting at all	TBD
Standing	Oswestry Disability Index: I can stand as long as I want without extra pain Â… I can stand as long as I want but it gives me extra pain Â… Pain prevents me from standing for more than one hour Â… Pain prevents me from standing for more than 30 minutes Â… Pain prevents me from standing for more than 10 minutes Â… Pain prevents me from standing at all	TBD
Sleeping	Oswestry Disability Index: Pain does not prevent me from sleeping well Â… I can sleep well only by using medication Â… Even when I take medication, I have less than 6 hrs sleep Â… Even when I take medication, I have less than 4 hrs sleep Â… Even when I take medication, I have less than 2 hrs sleep Â… Pain prevents me from sleeping at all	TBD
Social Life	Oswestry Disability Index: My social life is normal and gives me no extra pain Â… My social life is normal but increases the degree of pain Â… Pain has no significant effect on my social life apart from limiting my more energetic interests, i.e. dancing, etc. Â… Pain has restricted my social life and I do not go out as often Â… Pain has restricted my social life to my home Â… I have no social life because of pain	TBD
Traveling	Oswestry Disability Index: I can travel anywhere without extra pain Â… I can travel anywhere but it gives me extra pain Â… Pain is bad, but I manage journeys over 2 hours Â… Pain restricts me to journeys of less than 1 hour Â… Pain restricts me to short necessary journeys under 30 minutes Â… Pain prevents me from traveling except to the doctor or hospital	TBD
Employment/Homemaking	Oswestry Disability Index: My normal homemaking/ job activities do not cause pain. Â… My normal homemaking/ job activities increase my pain, but I can still perform all that is required of me. Â… I can perform most of my homemaking/ job duties, but pain prevents me from performing more physically stressful activities (e.g. lifting, vacuuming) Â… Pain prevents me from doing anything but light duties. Â… Pain prevents me from doing even light duties. Â… Pain prevents me from performing any job or homemaking chores.	TBD
In general, would you say your health is:	SF-36	TBD
Compared to one year ago, how would you rate your health in general now?	SF-36 Much better now than one year ago Somewhat better now than one year ago About the same Somewhat worse now than one year ago Much worse than one year ago	TBD
How satisfied are you with the level of care you are receiving by our providers and staff?	Practice related	TBD
Doctors are good about explaining the reason for medical tests.	PSQ-18	TBD
I think my health care provider's office has everything needed to provide complete medical care.	PSQ-18	TBD
The health care I have been receiving is just about perfect.	PSQ-18	TBD
Sometimes healthcare providers make me wonderif their diagnosis is correct.	PSQ-18 #4	TBD
I feel confident that I can get the healthcare I need without being set back financially.	PSQ-18 #5	TBD
My back pain has spread down my leg(s) at some time in the last 2 weeks	STarTBack #1	TBD
I have had pain in the shoulder or neck at some time in the last 2 weeks	STarTBack #2	TBD
I have only walked short distances because of my back pain	STarTBack #3	TBD
In the last 2 weeks, I have dressed more slowly than usual because of back pain	STarTBack #4	TBD
It's not really safe for a person with a condition like mine to be physically active	STarTBack #5	TBD
Worrying thoughts have been going through my mind a lot of the time	STarTBack #6	TBD
I feel that my back pain is terrible and it's never going to get any better	STarTBack #7	TBD
In general I have not enjoyed all the things I used to enjoy	STarTBack #8	TBD
Overall, how bothersome has your back pain been in the last 2 weeks?	STarT Back #9	TBD
Does your health now limit you in doing two hours of physical labor?	Promis Global Health v1.2	TBD
Does your health now limit you in doing strenuous activities such as backpacking, skiing, playing tennis, bicycling or jogging?	Promis Global Health v1.2	TBD
Are you able to run five miles?	Promis Global Health v1.2	TBD
Are you able to run ten miles?	Promis Global Health v1.2	TBD
Are you able to run at a fast pace for two miles?	Promis Global Health v1.2	TBD
Are you able to run or jog for two miles?	Promis Global Health v1.2	TBD
Are you able to run 100 yards?	Promis Global Health v1.2	TBD
Does your health now limit you in doing eight hours of physical labor?	Promis Global Health v1.2	TBD
Are you able to run 100 yards?	Promis Global Health v1.2	TBD
Open a tight or new jar.	QucikDASH#1	TBD
Do heavy household chores (e.g., wash walls, floors).	QucikDASH#2	TBD
Carry a shopping bag or briefcase.	QucikDASH#3	TBD
Wash your back.	QucikDASH #4	TBD
Use a knife to cut food.	QucikDASH #5	TBD
Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).	QucikDASH #6	TBD
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?	QucikDASH #11	TBD
During the past week, to what extent has your arm, shoulder, or hand problem interfered with your normal social activities with family, friends, neighbors?	Quick DASH #7	TBD
During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem.	Quick DASH #8	TBD
What has been the severity of the your arm, shoulder or hand pain?	Quick DASH #9	TBD
What has been the severity of the tingling in your arm, shoulder or hand?	Quick DASH #10	TBD
Any of your usual work, housework, or school activities.	LEFS #1	TBD
Your usual hobbies, recreational or sporting activities.	LEFS #2	TBD
Getting into or out of the bath.	LEFS #3	TBD
Walking between rooms.	LEFS #4	TBD
Putting on your shoes or socks.	LEFS #5	TBD
Squatting.	LEFS #6	TBD
Lifting an object, like a bag of groceries from the floor.	LEFS #7	TBD
Performing light activities around your home.	LEFS #8	TBD
Performing heavy activities around your home.	LEFS #9	TBD
Getting into or out of a car.	LEFS #10	TBD
Walking 2 blocks.	LEFS #11	TBD
Walking a mile.	LEFS #12	TBD
Going up or down 10 stairs (about 1 flight of stairs).	LEFS #13	TBD
Standing for 1 hour.	LEFS #14	TBD
Running on even ground.	LEFS #16	TBD
Running on uneven ground.	LEFS #17	TBD
Making sharp turns while running fast.	LEFS #18	TBD
Hoping.	LEFS #19	TBD
Sitting for 1 hour.	LEFS #15	TBD
Rolling over in bed.	LEFS #20	TBD
Over the past week, on average, how would you rate your back pain?	Bournemouth #1	TBD
Over the past week, how much has your back pain interfered with your daily activities (housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)?	Bournemouth #2	TBD
Over the past week, how much has your back pain interfered with your ability to take part in recreational, social, and family activities?	Bournemouth #3	TBD
Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing)have you been feeling?	Bournemouth #4	TBD
Over the past week, how depressed(down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling?	Bournemouth #5	TBD
Over the past week, how have you felt work (both inside and outside the home) has affected (or would affect) your back pain?	Bournemouth #6	TBD
Over the past week, how much have you been able to control (reduce/help) your back pain on your own?	Bournemouth #7	TBD
How successful have you been with following the recommendations of your health care provider for this past week?	Compliance	TBD
How satisfied are you currently with your providers office?	Clinic satisfaction	TBD
Cancer	Have you had cancer?	TBD
Pain intensity	Oswestry Disability Index v2.0	TBD
Personal care (washing, dressing, etc.)	Section 2 - Personal care (washing, dressing, etc.)	TBD
Personal care (washing, dressing, etc.)	Section 2 - Personal care (washing, dressing, etc.)	TBD
Lifting	Section 3 - Lifting I can lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned, e.g. on a table. Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. I can lift only very light weights. I cannot lift or carry anything at all.	TBD
Walking	Section 4 - Walking Pain does not prevent me walking any distance. Pain prevents me walking more than 1 mile. Pain prevents me walking more than than 1/2 of a mile. Pain prevents me walking more than 100 yards. I can only walk using a stick or crutches. I am in bed most of the time and have to crawl to the toilet.	TBD
Sitting	Section 5 - Sitting I can sit in any chair as long as I like. I can sit in my favourite chair as long as I like. Pain prevents me from sitting for more than 1 hour. Pain prevents me from sitting for more than 1/2 an hour. Pain prevents me from sitting for more than 10 minutes. Pain prevents me from sitting at all.	TBD
Standing	Section 6 - Standing I can stand as long as I want without extra pain. I can stand as long as I want but it gives me extra pain. Pain prevents me from standing for more than 1 hour. Pain prevents me from standing for more than 1/2 an hour. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing at all.	TBD
Sleeping	Section 7 - Sleeping My sleep is never disturbed by pain. My sleep is occasionally disturbed by pain. Because of pain I have less than 6 hours sleep. Because of pain I have less than 4 hours sleep. Because of pain I have less than 2 hours sleep. Pain prevents me from sleeping at all.	TBD
Sex life (if applicable)	Section 8 - Sex life (if applicable) My sex life is normal and causes no extra pain. My sex life is normal but causes some extra pain. My sex life is nearly normal but is very painful. My sex life is severely restricted by pain. My sex life is nearly absent because of pain. Pain prevents any sex life at all.	TBD
Social life	Section 9 - Social life My social life is normal and causes me no extra pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. sport, etc. Pain has restricted my social life and I do not go out as often. Pain has restricted social life to my home. I have no social life because of pain.	TBD
Traveling	Section 10 - Travelling I can travel anywhere without pain. I can travel anywhere but it gives extra pain. Pain is bad but I manage journeys over two hours. Pain restricts me to journeys of less than one hour. Pain restricts me to short necessary journeys under 30 minutes. Pain prevents me from travelling except to receive treatment.	TBD
Little interest or pleasure in doing things	Over the last 2 weeks, how often have you been bothered by any of the following problems? a. Little interest or pleasure in doing things	TBD
Feeling down, depressed, or hopeless	Over the last 2 weeks, how often have you been bothered by any of the following problems? Feeling down, depressed, or hopeless	TBD
Trouble falling/staying asleep, sleeping too much	Trouble falling/staying asleep, sleeping too much	TBD
Feeling tired or having little energy	Over the last 2 weeks, how often have you been bothered by any of the following problems? Feeling tired or having little energy	TBD
Poor appetite or overeating	Over the last 2 weeks, how often have you been bothered by any of the following problems? Poor appetite or overeating	TBD
Feeling bad about yourself or that you are a failure or have let yourself or your family down	Over the last 2 weeks, how often have you been bothered by any of the following problems? Feeling bad about yourself or that you are a failure or have let yourself or your family down	TBD
Trouble concentrating on things, such as reading the newspaper or watching television.	Over the last 2 weeks, how often have you been bothered by any of the following problems? Trouble concentrating on things, such as reading the newspaper or watching television.	TBD
Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around a lot more than usual.	Over the last 2 weeks, how often have you been bothered by any of the following problems? Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around a lot more than usual.	TBD
Thoughts that you would be better off dead or of hurting yourself in some way.	Over the last 2 weeks, how often have you been bothered by any of the following problems? Thoughts that you would be better off dead or of hurting yourself in some way.	TBD
If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?	If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?	TBD
Please indicate your usual level of pain during the past week:	Please indicate your usual level of pain during the past week:	TBD
Does pain, numbness, tingling or weakness extend into your leg (from the low back) and/or arm (from the neck)?	Does pain, numbness, tingling or weakness extend into your leg (from the low back) &/or arm (from the neck)?	TBD
How would you rate your general health?	How would you rate your general health?	TBD
If you had to spend the rest of your life with your condition as it is right now, how would you feel about it?	If you had to spend the rest of your life with your condition as it is right now, how would you feel about it?	TBD
How anxious (tense, uptight, irritable, fearful, difficulty in concentrating / relaxing) you have been feeling during the past week:	How anxious (tense, uptight, irritable, fearful, difficulty in concentrating / relaxing) you have been feeling during the past week:	TBD
How much you have been able to control (reduce/help) your pain/ complaint on your own during the past week:	How much you have been able to control (reduce/help) your pain/ complaint on your own during the past week:	TBD
Please indicate how depressed (eg. Down-in-the-dumps, sad, downhearted, in low spirits, pessimistic, feelings of hopelessness) you have been feeling in the past week:	Please indicate how depressed (eg. Down-in-the-dumps, sad, downhearted, in low spirits, pessimistic, feelings of hopelessness) you have been feeling in the past week:	TBD
On a scale of 0 to 10, how certain are you that you will be doing normal activities or working in six months?	On a scale of 0 to 10, how certain are you that you will be doing normal activities or working in six months?	TBD
I can do light work for an hour.	I can do light work for an hour.	TBD
I can sleep at night.	I can sleep at night.	TBD
An increase in pain is an indication that I should stop what I am doing until the pain decreases.	An increase in pain is an indication that I should stop what I am doing until the pain decreases.	TBD
Physical activity makes my pain worse.	Physical activity makes my pain worse.	TBD
I should not do my normal activities including work with my present pain.	I should not do my normal activities including work with my present pain.	TBD
Feeling nervous, anxious or on edge	Over the last 2 weeks, how often have you been bothered by any of the following problems? Feeling nervous, anxious or on edge	TBD
Not being able to stop or control worrying	Over the last 2 weeks, how often have you been bothered by any of the following problems? Not being able to stop or control worrying	TBD
Trouble concentrating on things like school work, reading, or watching television?	Over the last 2 weeks, how often have you been bothered by any of the following problems? Trouble concentrating on things, such as reading the newspaper or watching television.	TBD
In the past year, have you felt depressed or sad most days even if you felt okay sometimes?	In the past year, have you felt depressed or sad most days even if you felt okay sometimes?	TBD
If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?	If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people.	TBD
Has there been a time in the past month when you have had serious thoughts about ending your life?	Has there been a time in the past month when you have had serious thoughts about ending your life?	TBD
Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?	Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?	TBD
Stomach pain	PHQ-15 Physical Symptoms #a The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Back pain	PHQ-15 Physical Symptoms #b The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Pain in your arms, legs, or joints (knees, hips, etc)	PHQ-15 Physical Symptoms #c The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Menstrual cramps or other problems with your periods (Women Only)	PHQ-15 Physical Symptoms #d The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Headaches	PHQ-15 Physical Symptoms #e The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Chest pain	PHQ-15 Physical Symptoms #f The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Dizziness	PHQ-15 Physical Symptoms #g The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Fainting spells	PHQ-15 Physical Symptoms #h The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Feeling your heart pound or race	PHQ-15 Physical Symptoms #i The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Shortness of breath	PHQ-15 Physical Symptoms #j The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Pain or problems during sexual intercourse	PHQ-15 Physical Symptoms #k The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Constipation, loose bowels, or diarrhea	PHQ-15 Physical Symptoms #l The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Nausea, gas, or indigestion	PHQ-15 Physical Symptoms #m The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Feeling tired or having low energy	PHQ-15 Physical Symptoms #n The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Trouble sleeping	PHQ-15 Physical Symptoms #o The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.	TBD
Worrying too much about different things	Over the last 2 weeks, how often have you been bothered by any of the following problems? Worrying too much about different things	TBD
Trouble relaxing	Over the last 2 weeks, how often have you been bothered by any of the following problems? Trouble relaxing	TBD
Being so restless that it is hard to sit still	Over the last 2 weeks, how often have you been bothered by any of the following problems? Being so restless that it is hard to sit still	TBD
Becoming easily annoyed or irritable	Over the last 2 weeks, how often have you been bothered by any of the following problems? Becoming easily annoyed or irritable	TBD
Feeling afraid as if something awful might happen	Over the last 2 weeks, how often have you been bothered by any of the following problems? Feeling afraid as if something awful might happen	TBD
Difficulty hearing	Difficulty hearing	TBD
Ringing in ear	Tinnitus/Ringing in ear	TBD
Sore throat	Sore throat/Pharyngitis	TBD
Swelling of feet or legs	Swelling of feet or legs	TBD
Pain in legs with walking	Pain in legs with walking	TBD
Coughing up blood	Coughing up blood/Hemoptysis	TBD
Blood in stool	Blood in stool/	TBD
Painful urination	Painful urination/Dysuria	TBD
Prostate problems	Prostate problems	TBD
Bladder problems	Bladder problems	TBD
Impotence	Impotence	TBD
Hair loss	Hair loss	TBD
Weakness	Weakness	TBD
Problems with walking or balance	Problems with walking or balance	TBD
Intolerance to heat or cold	Intolerance to heat or cold	TBD
Changes in sex drive	Changes in sex drive	TBD
Anemia	Anemia	TBD
Anemia	Anemia	TBD
Leukemia	Leukemia	TBD
Seasonal Allergies	Seasonal Allergies	TBD
Frequent Infections	Frequent Infections	TBD
Heartburn	Heartburn	TBD
Shoulder pain	Shoulder pain	TBD
Hip pain	Hip pain	TBD
Knee pain	Knee pain	TBD
Ankle pain	Ankle pain	TBD
Foot pain	Foot pain	TBD
Wrist pain	Wrist pain	TBD
Aching muscles	Aching muscles	TBD
Admin pass fail	admin only	TBD
Admin neck B	cs	TBD
Itchy nose	In the past week have you been bothered by and itchy nose?	TBD
Running nose	In the past week, have you had a runny nose?	TBD
Runny nose	Have you had a runny nose in the past week? If yes, was the discharge clear or colored?	TBD
Did any doctor diagnose you with an allergic disease?	AQUA©: Allergy Questionnaire for Athletes. Question 4 Additional elements include specific diagnosis (Asthma, Rhinnitis, Conjunctivitis etc).	TBD
Do you frequently sneeze, have a runny, itchy nose, (apart from colds)?	AQUA©: Allergy Questionnaire for Athletes. Question 9	TBD
Do you suspect you suffer from allergy, independent from any medical diagnosis. ?	AQUA©: Allergy Questionnaire for Athletes. Question 5	TBD
Have you ever had an allergic reaction to foods?	AQUA©: Allergy Questionnaire for Athletes. Question 15	TBD
Did you ever use anti-allergic drugs (antihistamines, topical steroids, "allergy vaccines")?	AQUA©: Allergy Questionnaire for Athletes. Question 6	TBD
Shortness of breath	Shortness of breath	TBD
Itchy/Watery Eyes	Itchy/watery eyes may also be referred to as conjunctivitis.	TBD
Cough	Do you frequently experience coughing?	TBD
Eyelid swelling	Do you experience eyelid swelling	TBD
Facial Pressure or Pain	Do you experience facial pressure or pain?	TBD
admin head axial	a	TBD
admin head bilateral	b	TBD
Lower Back Pain VAS	This question represents the visual analogue scale measurements for lower back pain. This includes the lumbar spine as well as the pelvis/sacrum area.	TBD
Get out of bed	The Quebec Back Pain Disability Scale: Question 1 Today, do you find it difficult to perform the following activities because of your back?	TBD
Sleep through the night	The Quebec Back Pain Disability Scale: Question 2 Today, do you find it difficult to perform the following activities because of your back?	TBD
Turn over in bed	The Quebec Back Pain Disability Scale: Question 3 Today, do you find it difficult to perform the following activities because of your back?	TBD
Ride in a car	The Quebec Back Pain Disability Scale: Question 4 Today, do you find it difficult to perform the following activities because of your back?	TBD
Stand up for 20-30 minutes	The Quebec Back Pain Disability Scale: Question 5 Today, do you find it difficult to perform the following activities because of your back?	TBD
Sit in a chair for several hours	The Quebec Back Pain Disability Scale: Question 6 Today, do you find it difficult to perform the following activities because of your back?	TBD
Climb one flight of stairs	The Quebec Back Pain Disability Scale: Question 7 Today, do you find it difficult to perform the following activities because of your back?	TBD
Walk a few blocks (300-400m)	The Quebec Back Pain Disability Scale: Question 8 Today, do you find it difficult to perform the following activities because of your back?	TBD
Walk several kilometers	The Quebec Back Pain Disability Scale: Question 9 Today, do you find it difficult to perform the following activities because of your back?	TBD
Reach up to high shelves	The Quebec Back Pain Disability Scale: Question 10 Today, do you find it difficult to perform the following activities because of your back?	TBD
Throw a ball	The Quebec Back Pain Disability Scale: Question 11 Today, do you find it difficult to perform the following activities because of your back?	TBD
Run one block (about 100m)	The Quebec Back Pain Disability Scale: Question 12 Today, do you find it difficult to perform the following activities because of your back?	TBD
Take food out of the refrigerator	The Quebec Back Pain Disability Scale: Question 13 Today, do you find it difficult to perform the following activities because of your back?	TBD
Make your bed	The Quebec Back Pain Disability Scale: Question 14 Today, do you find it difficult to perform the following activities because of your back?	TBD
Put on socks (pantyhose)	The Quebec Back Pain Disability Scale: Question 15 Today, do you find it difficult to perform the following activities because of your back?	TBD
Bend over to clean the bathtub	The Quebec Back Pain Disability Scale: Question 16 Today, do you find it difficult to perform the following activities because of your back?	TBD
Move a chair	The Quebec Back Pain Disability Scale: Question 17 Today, do you find it difficult to perform the following activities because of your back?	TBD
Pull or push heavy doors	The Quebec Back Pain Disability Scale: Question 18 Today, do you find it difficult to perform the following activities because of your back?	TBD
Carry two bags of groveries	The Quebec Back Pain Disability Scale: Question 19 Today, do you find it difficult to perform the following activities because of your back?	TBD
Lift and carry a heavy suitcase	The Quebec Back Pain Disability Scale: Question 20 Today, do you find it difficult to perform the following activities because of your back?	TBD
Neck Pain VAS	This question represents the visual analogue scale measurements for neck back pain.	TBD
Thoracic Pain VAS	This question represents the visual analogue scale measurements for thoracic back pain. This includes the thoracic cage including vertebrae, ribs and sternum	TBD
Do you have any Pain?	I want to know if you have any Pain.	TBD
In the past 7 days - How often do you feel tired?	PROMIST Short Form 7	TBD
For how many years did you (have you) smoke(d) up to now?	For how many years did you (have you) smoke(d) up to now?	TBD
Chills	Chills is a feeling of coldness occurring during a high fever, but sometimes is also a common symptom which occurs alone in specific people. It occurs during fever due to the release of cytokines and prostaglandins as part of the inflammatory response, which increases the set point for body temperature in the hypothalamus. The increased set point causes the body temperature to rise (pyrexia), but also makes the patient feel cold or chills until the new set point is reached. Shivering also occurs along with chills because the patient's body produces heat during muscle contraction in a physiological attempt to increase body temperature to the new set point.[1] When it does not accompany a high fever, it is normally a light chill. Sometimes a chill of medium power and short duration may occur during a scare, especially in scares of fear, commonly interpreted like or confused by trembling.	TBD
Pain/stiffness during the day How severe was your usual joint or muscle pain and/or stiffness overall during the day in the last 2 weeks?	Pain/stiffness during the day How severe was your usual joint or muscle pain and/or stiffness overall during the day in the last 2 weeks?	TBD

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Regions

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Regions

Cervical

Thoracic

Lumbar

Pelvic

Hip

Knee

Ankle

Foot

Shoulder

Elbow

Wrist

Hand

Head

TMJ

Systemic