DR. RICHARD BUSCH

1

Name

First Name

Last Name

2

Phone Number

Area Code

Phone Number

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Your Best Email Address

example@example.com

4

The following list of questions contains sentences that people have used to describe themselves when they have back pain. When you read them, you may find that some stand out because they describe you today. As you read the list, please think of yourself today. When you read a sentence that describes how you feel today, please select YES. If the sentance does not describe you, please select NO. Please remember to only say YES if you are sure that it describes you today.

5

I change position frequently to try to get my back/neck comfortable.

YESNO

6

I walk more slowly than usual because of my back.

YESNO

7

Because of my back/neck pain I don't do the jobs that I usually do around the house.

YESNO

8

I only stand and/or walk short periods of because of my back pain.

YESNO

9

I find it difficult to get out of a chair because of my back.

YESNO

10

My back/neck is painful almost all the time.

YESNO

11

I have trouble putting on my socks (or stockings) because of the pain in my back.

YESNO

12

I sleep less well because of my back/neck pain.

YESNO

13

Because of my back/neck pain, I am more irritable and bad tempered with people than usual.

YESNO

14

Rate the severity of your pain by selecting one of the stars below.1 = NO PAIN | 10 = UNBEARABLE PAIN

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10

NO PAIN

UNBEARABLE PAIN