HeartCloud | For Patients & Individuals

Question 1:

Over the last 24 hours, did you experience Cervical Dystonia symptoms?

Green circle with white checkmark aligned vertically and horizontally in middle

Yes

Question 1(a):

Choose one of the following that best describes the severity of your Cervical Dystonia symptoms in the last 24 hours on a 1-5 scale, using the faces as a guide:

Slight	Mild	Moder.	Severe	Worst
1 2 3 4 5

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Question 1(b):

Which postures interfered with your movement in the last 24 hours?

Rotation L/R

Tilt L/R

Anterocollis (head tilt forward)

Retrocollis (head tilt back)

Shoulder Elevation

None

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Question 1(c):

Which of the following symptoms (if any) did you experience over the last 24 hours?

Head Tremor/Jerks

Lost Balance

Fall

None

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Question 1(d):

How long did symptoms bother you in the last 24 hours

Not At All

Less Than 10 Min

10 - 60 Min

Over 60 Min

Most Of The Day

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Question 1(e):

New trouble swallowing or breathing from neck posture in the last 24 hours?

Yes

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Question 2:

In the last 24 hours, how much did symptoms limit your usual activities?

Activities were not limited.

Activities were mildly limited.

Activities were moderately limited.

Activities were severely limited.

I could not do usual activities.

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Question 2(a):

Which activities did your symptoms prevent you from participating in? (Select all that apply)

Work

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Reading

Driving

3 user icons (yellow, orange-ish red, and lilac) with yellow chat boxes above the first and third icons from left, respectively

Social Activities

Red blanket and pillow on light brown frame

Restful Sleep

Self-care (groom/eat)

Red heart with pointed lines and free weight

Hobbies/exercise

No Disability

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Question 3:

Over the last 24 hours, did you experience neck/shoulder pain?

Yes

Question 3(a):

How severe was your neck/shoulder pain in the last 24 hours using the faces as a guide:

Slight	Mild	Moder.	Severe	Worst
1 2 3 4 5

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Question 3(b):

Where was the pain located? (Select all that apply)

Neck

Shoulder

Back of head

Other

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Question 3(c):

How many doses of pain medicine have you used in the last 24 hours?

0 doses

1 - 2

3 or more

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Question 4:

Did you take your dystonia medications as prescribed in the last 24 hours?

Yes (All)

yellow circle with white checkmark aligned vertically and horizontally in middle

Yes (Some)

Not Applicable

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Question 4(a):

Did you complete your therapy tasks (stretches/PT/exercise) in the last 24 hours?

Yes (All)

Yes (Some)

Not Applicable

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Question 4(b):

Did you use any sensory trick(s) in the last 24 hours?

Not used

Used and helped

Used but did not help

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Question 4(c):

Did you experience botulinum toxin wearing‑off in the last 24 hours?

None

Mild

Moderate

Severe

Not Sure

Not Applicable

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Question 1:

Question 1(a):

Yes

No

Question 1(b):

Question 1(c):

Question 1(d):

Question 1(e):

Question 2:

Question 2(a):

Question 3:

Question 3(a):

Yes

No

Question 3(b):

Question 3(c):

Question 4:

Question 4(a):

Question 4(b):

Question 4(c):

Apps:

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Question 1:

Question 1(a):

Yes

No

Question 1(b):

Question 1(c):

Question 1(d):

Question 1(e):

Question 2:

Question 2(a):

Question 3:

Question 3(a):

Yes

No

Question 3(b):

Question 3(c):

Question 4:

Question 4(a):

Question 4(b):

Question 4(c):

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