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Dr. Antonacci
Meet M. Darryl Antonacci MD, FACS
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Drs. ABC
Drs. ABC
Dr. A – Darryl Antonacci MD, FACS
Dr. B – Randal R. Betz, MD
Dr. C – Laury A. Cuddihy, MD
The Institute for Spine & Scoliosis Team
Real Scoliosis Stories
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Dr. Antonacci
Meet M. Darryl Antonacci MD, FACS
Positions & Education
Awards & Honors
Drs. ABC
Drs. ABC
Dr. A – Darryl Antonacci MD, FACS
Dr. B – Randal R. Betz, MD
Dr. C – Laury A. Cuddihy, MD
The Institute for Spine & Scoliosis Team
Real Scoliosis Stories
What Is ASC?
About ASC
VBT and ASC Surgeries Compared
Scoliosis Surgery Before and After
Testimonials
Scoliosis Spinal Surgery Frequently Asked Questions
For New Patients
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Review My Scoliosis Case
Review My Scoliosis Case
New
Patient Hotline:
888-503-0244
Returning
Patient Inquiries:
609-912-1500
Facebook
Instagram
Youtube
Twitter
Dr. Antonacci
Meet M. Darryl Antonacci MD, FACS
Positions & Education
Awards & Honors
Drs. ABC
Drs. ABC
Dr. A – Darryl Antonacci MD, FACS
Dr. B – Randal R. Betz, MD
Dr. C – Laury A. Cuddihy, MD
The Institute for Spine & Scoliosis Team
Real Scoliosis Stories
What Is ASC?
About ASC
VBT and ASC Surgeries Compared
Scoliosis Surgery Before and After
Testimonials
Scoliosis Spinal Surgery Frequently Asked Questions
For New Patients
Locations
News
Dr. Antonacci
Meet M. Darryl Antonacci MD, FACS
Positions & Education
Awards & Honors
Drs. ABC
Drs. ABC
Dr. A – Darryl Antonacci MD, FACS
Dr. B – Randal R. Betz, MD
Dr. C – Laury A. Cuddihy, MD
The Institute for Spine & Scoliosis Team
Real Scoliosis Stories
What Is ASC?
About ASC
VBT and ASC Surgeries Compared
Scoliosis Surgery Before and After
Testimonials
Scoliosis Spinal Surgery Frequently Asked Questions
For New Patients
Locations
News
New Patients
888-503-0244
Returning Patients
609-912-1500
Do you need spine surgery?
Review My Scoliosis Case
SRS-22r Patient Questionnaire
This form requires your MRN number, provided through the Institute for Spine & Scoliosis office. Please contact us for an updated link to this form.
Today’s Date
Patient Name
First Name
*
Middle Initial
Last Name
*
Patient's Sex
*
Questions
1) Which one of the following best describes the amount of pain you have experienced during the past 6 months?
None
Mild
Moderate
Moderate to severe
Severe
2) Which one of the following best describes the amount of pain you have experienced over the last month?
None
Mild
Moderate
Moderate to severe
Severe
3) During the past 6 months have you been a very nervous person?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
4) If 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 happy
Somewhat happy
Neither happy nor unhappy
Somewhat unhappy
Very unhappy
5) What is your current level of activity?
Bedridden
Primarily no activity
Light labor and light sports
Moderate labor and moderate sports
Full activities without restriction
6) How do you look in clothes?
Very good
Good
Fair
Bad
Very bad
7) In the past 6 months have you felt so down in the dumps that nothing could cheer you up?
Very often
Often
Sometimes
Rarely
Never
8) Do you experience back pain when at rest?
Very often
Often
Sometimes
Rarely
Never
9) What is your current level of work/school activity?
100% normal
75% normal
50% normal
25% normal
0% normal
10) Which of the following best describes the appearance of your trunk; defined as the human body except for the head and extremities?
Very good
Good
Fair
Poor
Very Poor
11) Which one of the following best describes your pain medication use for back pain?
None
Non-narcotics weekly or less (e.g., aspirin, Tylenol, Ibuprofen)
Non-narcotics daily
Narcotics weekly or less (e.g. Tylenol III, Lorcet, Percocet)
Narcotics daily
12) Does your back limit your ability to do things around the house?
Never
Rarely
Sometimes
Often
Very Often
13) Have you felt calm and peaceful during the past 6 months?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
14) Do you feel that your back condition affects your personal relationships?
None
Slightly
Mildly
Moderately
Severely
15) Are you and/or your family experiencing financial difficulties because of your back?
Severely
Moderately
Mildly
Slightly
None
16) In the past 6 months have you felt down hearted and blue?
Never
Rarely
Sometimes
Often
Very often
17) In the last 3 months have you taken any days off of work, including household work, or school because of back pain?
0 days
1 day
2 days
3 days
4 or more days
18) Does your back condition limit your going out with friends/family?
Never
Rarely
Sometimes
Often
Very often
19) Do you feel attractive with your current back condition?
Yes, very
Yes, somewhat
Neither attractive nor unattractive
No, not very much
No, not at all
20) Have you been a happy person during the past 6 months?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
21) Are you satisfied with the results of your back management?
Very satisfied
Satisfied
Neither satisfied nor unsatisfied
Unsatisfied
Very unsatisfied
22) Would you have the same management again if you had the same condition?
Definitely yes
Probably yes
Not sure
Probably not
Definitely not
23) I felt angry when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
24) I had trouble doing schoolwork when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
25) I had trouble sleeping when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
26) It was hard for me to pay attention when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
27) It was hard for me to run when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
27) It was hard for me to walk one block when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
28) It was hard to have fun when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
29) It was hard to stay standing when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
30) I hurt a lot
Never
Almost Never
Sometimes
Often
Almost Always
31) I hurt all over my body
Never
Almost Never
Sometimes
Often
Almost Always
32) I missed school when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
33) It was hard for me to remember things when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
34) It was hard to get along with other people when I had pain
Never
Almost Never
Sometimes
Often
Almost Always
35) It was hard for me to be away from home because I had pain
Never
Almost Never
Sometimes
Often
Almost Always
35) It was hard to have fun with friends because I was in pain
Never
Almost Never
Sometimes
Often
Almost Always
36) I needed help walking when I was in pain
Never
Almost Never
Sometimes
Often
Almost Always
37) I walked carefully when I was in pain
Never
Almost Never
Sometimes
Often
Almost Always
38) I had so much pain I had to stop what I was doing
Never
Almost Never
Sometimes
Often
Almost Always
40) My pain was so bad that I needed to take medicine to treat it
Never
Almost Never
Sometimes
Often
Almost Always
41) It was hard to do things with my family because I had pain
Never
Almost Never
Sometimes
Often
Almost Always
Thank you for completing this questionnaire. Please comment if you wish.
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