TWSTRS Patient Self-Report | headacheMD® Houston

Sections II and III are completed by you before your visit. Section I will be completed by your provider during your appointment. The final TWSTRS score will be calculated by your provider at that time.

Your TWSTRS self-report has been submitted. Your headacheMD® provider will complete the assessment during your visit.

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Patient Information First Name Last Name Date of Birth Appointment / Visit Date Phone Number Email (optional — used to send you a copy)

II. Disability Scale (Maximum = 30)

Please rate how much Cervical Dystonia — the neck muscle condition you are being evaluated for — affects each of the following activities.

A. Work (Occupation or housework/home management)

0 = No difficulty 1 = Normal work with some interference from Cervical Dystonia 2 = Most activities unlimited; selected activities very difficult and hampered but still possible with satisfactory performance 3 = Working at lower-than-usual occupation level; most activities hampered but still possible with less-than-satisfactory performance in some 4 = Unable to engage in voluntary or gainful employment; still able to perform some domestic responsibilities satisfactorily 5 = Marginal or no ability to perform domestic responsibilities

B. Activities of Daily Living (e.g., eating, dressing, or hygiene including washing, shaving, makeup, etc.)

0 = No difficulty with any activity 1 = Activities unlimited but some interference from Cervical Dystonia 2 = Most activities unlimited; selected activities very difficult but still possible using simple tricks 3 = Most activities hampered or laborious but still possible; may use extreme tricks 4 = Dependent on others in most self-care tasks 5 = Dependent on others for most self-care tasks (maximum dependence)

C. Driving

0 = No difficulty (or has never driven a car) 1 = Unlimited ability to drive but bothered by Cervical Dystonia 2 = Unlimited ability but requires tricks (e.g., touching face, holding head against headrest) to control Cervical Dystonia 3 = Can drive only short distances 4 = Usually cannot drive because of Cervical Dystonia 5 = Unable to drive and cannot ride in a car for long stretches as a passenger

D. Reading

0 = No difficulty 1 = Unlimited ability to read in normal seated position but bothered 2 = Unlimited ability to read in normal seated position but requires use of tricks 3 = Unlimited ability but requires extensive measures, or is able to read only in nonseated position (e.g., lying down) 4 = Limited ability to read because of Cervical Dystonia despite tricks 5 = Unable to read more than a few sentences because of Cervical Dystonia

E. Watching Television

0 = No difficulty 1 = Unlimited ability to watch TV in normal seated position but bothered 2 = Unlimited ability but requires use of tricks 3 = Unlimited ability but requires extensive measures, or able to view only in nonseated position (e.g., lying down) 4 = Limited ability to watch television because of Cervical Dystonia 5 = Unable to watch television more than a few minutes because of Cervical Dystonia

F. Activities Outside the Home (e.g., shopping, walking, movies, dining, and other recreational activities)

0 = No difficulty 1 = Unlimited activities but bothered by Cervical Dystonia 2 = Unlimited activities but requires simple tricks to accomplish 3 = Accomplishes activities only when accompanied by others 4 = Limited activities; certain activities impossible or given up 5 = Rarely, if ever, engages in activities outside the home

Disability Subtotal: — / 30

III. Pain Scale (Maximum = 20)

The following questions are about neck pain related to your Cervical Dystonia over the last week.

A. Severity of Pain

Rate the severity of neck pain due to Cervical Dystonia during the last week on a scale of 0–10, where 0 represents no pain and 10 represents the most excruciating pain imaginable.

Best (lowest pain in past week)

Worst (highest pain in past week)

Usual (typical pain level in past week)

Calculated Severity Score (0–10): —
Score = (Worst + Best + [2 × Usual]) ÷ 4

Your provider will record this score — you do not need to calculate it yourself.

B. Duration of Pain

0 = None 1 = Present less than 10% of the time 2 = Present 10–25% of the time 3 = Present 26–50% of the time 4 = Present 51–75% of the time 5 = Present more than 75% of the time

C. Disability Due to Pain

0 = No limitation or interference from pain 1 = Pain is quite bothersome but not a source of disability 2 = Pain definitely interferes with some tasks but is not a major contributor to disability 3 = Pain accounts for some (less than half) but not all of disability 4 = Pain is a major source of difficulty with activities; head pulling is also a source of some (less than half) of disability 5 = Pain is the major source of disability; without it most impaired activities could be performed satisfactorily despite head pulling

Pain Subtotal: — / 20

Your Score Summary

Section II — Disability Subtotal:— / 30

Section III — Pain Subtotal:— / 20

Your Self-Report Total:— / 50

Section I (Severity, max 35) will be completed by your headacheMD® provider during your visit. The full TWSTRS total will be calculated at that time.

Signature & Submission

I confirm I have completed this form truthfully and to the best of my ability.

Type your full name as your electronic signature

Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) — Patient Self-Report

Your Score Summary