Table 1.
A questionnaire about the physical function of the cervical spine and the spinal cord
| C-1 Can you fasten the front buttons of your blouse or shirt using both hands? |
| C-2 Can you fasten the buttons of your blouse or shirt using only the right hand? |
| C-3 Can you fasten the buttons of your blouse or shirt using only the left hand? |
| C-4 Can you fasten the uppermost button of your blouse or shirt? |
| C-5 Can you fasten the cuff buttons of your blouse or shirt? |
| C-6 Can you turn the pages of a book or a newspaper? |
| C-7 Can you eat a meal using a spoon or a fork with your right hand? |
| C-8 Can you eat a meal using a spoon or a fork with your left hand? |
| C-9 Can you eat a meal using a pair of chopsticks? |
| C-10 Can you remove fish bones using a pair of chopsticks? |
| C-11 Does your right hand reach your mouth? |
| C-12 Does your left hand reach your mouth? |
| The items of a reply to these questions from C-1 to C-12 are below: |
| 1) I can do it without difficulty. |
| 2) I can do it if I spend time. |
| 3) I cannot do it. |
| 0) I am not sure. |
| C-13 Can you raise your right arm? |
| C-14 Can you raise your left arm? |
| The items of a reply to these questions are below: |
| 1) I can raise it straight upward. |
| 2) I can raise it upward when flexed a little. |
| 3) I can raise it halfway (up to shoulder level). |
| 4) I cannot raise it. |
| C-15 Can you remain sitting on a chair without leaning on the backrest? |
| 1) I can do it for the time necessary to have a meal. |
| 2) I can do it for the time necessary to change clothes. |
| 3) I can do it for the time necessary to use a toilet (evacuation of bowels). |
| 4) I cannot do it. |
| 0) I am not sure. |
| C-16 Can you stand up from the sitting position (on your own), without the assistance of other people, or without the support of a handrail or a stick? |
| 1) I can do it without difficulty. |
| 2) I can do it if I take time. |
| 3) I cannot do it. |
| 0) I am not sure. |
| C-17 Can you keep standing (on your own), without the assistance of other people, or without the support of a handrail or a stick? |
| 1) I can do it for a while (more than 3 minutes). |
| 2) I can do it for a short time (about a minute). |
| 3) I cannot do it. |
| 0) I am not sure. |
| C-18 Can you walk on a flat surface? |
| 1) I can do it without difficulty. |
| 2) I can do it slowly. |
| 3) I can do it with support (of a handrail, a stick, or a walker). |
| 4) I can do it only slowly even with support. |
| 5) I cannot do it. |
| 0) I am not sure. |
| C-19 Can you go up the stairs without holding the handrail? |
| C-20 Can you go down the stairs without holding the handrail? |
| The items of a reply to these questions are below: |
| 1) I can do it without difficulty. |
| 2) I can do it if I take time. |
| 3) I cannot do it. |
| 0) I am not sure. |
| C-21 Can you stand on your right leg without the support of your hand? |
| C-22 Can you stand on your left leg without the support of your hand? |
| The items of a reply to these questions are below: |
| 1) I can do it for more than 10 seconds. |
| 2) I can do it for less than 10 seconds. |
| 3) I can hardly do it. |
| 0) I am not sure. |
| C-23 Can you jump on your right leg? |
| C-24 Can you jump on your left leg? |
| The items of a reply to these questions are below: |
| 1) I can do it ( ) times. (Put the number of times in the blank). |
| 2) I can hardly do it. |
| 0) I am not sure. |
| C-25 Can you walk at a quick pace? |
| C-26 Can you trot? (By “trot” we mean moving fairly fast at a speed between walking and running, taking small quick steps.) |
| The items of a reply to these questions are below: |
| 1) I can do it without difficulty. |
| 2) I cannot do it. |
| 0) I am not sure. |
| C-27 Do you need a catheter (an artificial tube) insertion to void urine (for urination)? |
| 1) I do not need it. |
| 2) I usually do not need it. |
| 3) I sometimes need it, sometimes not. |
| 4) I usually need it. |
| C-28 Do you have urinary incontinence? |
| 1) No. |
| 2) I have it when I sneeze or strain myself. |
| 3) I have it when I do not release urine over a period of more than two hours. |
| 4) Frequently. |
| 5) Always. |
| C-29 Can you void urine without strain? |
| 1) I can do it. |
| 2) I cannot do it without strain. |
| 3) I cannot do it by myself. |
| C-30 How often do you go to the bathroom (to void urine) at night? |
| 1) Hardly ever |
| 2) Once or twice. |
| 3) Three times or more. |
| C-31 Do you have a feeling of residual urine even after voiding of urine (urination)? |
| 1) I rarely have such a feeling. |
| 2) I sometimes have such a feeling, and sometimes not. |
| 3) I usually have such a feeling. |
| 0) I am not sure. |
| C-32 Can you void urine immediately in the toilet? |
| 1) I almost always can do it immediately. |
| 2) I sometimes can do it immediately, and sometimes not. |
| 3) I usually cannot do it immediately. |
| 0) I am not sure. |
| C-33 Do you have bowel movements (evacuations) every day? |
| 1) I have more than one movement almost every day. |
| 2) I have a movement almost every day. |
| 3) I have a movement about every other day. |
| 4) I have a movement about every three days. |
| 5) I have a movement more than every three days. |
| C-34 [Question for men]. Have you ever been told at a urology department that you had prostate hypertrophy? |
| 1) No. |
| 2) Yes, but I have not had treatment. |
| 3) Yes, I have. I underwent medical treatment and it was cured. |
| 4) Yes, I have. I have been undergoing medical treatment. |
| C-35. While in the sitting position, can you look up at the ceiling by drawing your head directly backward? |
| 1) I can do it without difficulty. |
| 2) I can do it with some effort. |
| 3) I cannot do it. |
| C-36. Can you gargle? |
| C-37. Can you drink a glass of water in one gulp? |
| C-38. Can you see your feet when you walk down the stairs? |
| C-39. While in the sitting position, can you turn your head toward the person seated on your right side without moving your body? |
| C-40. While in the sitting position, can you turn your head toward the person seated on your left side without moving your body? |
| The items of a reply to these questions from C-36 to C-40 are below: |
| 1) I can do it without difficulty. |
| 2) I can do it with some effort. |
| 3) I cannot do it. |
| 0) I am not sure. |
| C-41. Can you turn your head when you back your car? |
| 1) I can do it without difficulty. |
| 2) I can do it with some effort. |
| 3) I cannot do it. |
| 0) I am not sure. I do not drive a car/I do not drive these days. |