Low Back Pain Questionnaire
This form is designed to give information about how your back pain is affecting your everyday life. In each section, mark the box which best applies to you. If two of the statements in one section may relate to you, please mark the one box which most closely describes your problem. Please read all selections before choosing the appropriate answer.
Date of Birth
Please select your physician from the list below:
Eric Amundson, MD
Philip Azordegan, MD
John D. Davis, IV, MD
Jack Moriarity, MD
W. Lynn Stringer, MD
Matthew VanLandingham, MD
Kelsey A. Walsh, MD
E. Greg Wood, III, MD
Is today's visit a pre-operative/consultation visit or a post-operative/follow-up visit?
Section 1-Pain Intensity
I have no pain at the moment.
The pain is very mild at the moment.
The pain is moderate at the moment.
The pain is fairly severe at the moment.
The pain is very severe at the moment.
The pain is the worst imaginable at the moment.
I can lift heavy weights without extra pain.
I can lift heavy weights but it gives extra pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (i.e. on a table).
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if conveniently positioned.
I can lift only very light weights.
I cannot lift or carry anything at all.
I can sit in any chair as long as I like.
I can sit in my favorite chair as long as I like.
Pain prevents me from sitting for more than 1 hour.
Pain prevents me from sitting for more than 1/2 an hour.
Pain prevents me from sitting for more than 10 minutes.
Pain prevents me from sitting at all.
I can stand as long as I want without extra pain.
I can stand as long as I want but it gives me extra pain.
Pain prevents me from standing for more than 1 hour.
Pain prevents me from standing for more than 1/2 an hour.
Pain prevents me from standing for more than 10 minutes.
Pain prevents me from standing at all.
Pain does not prevent me walking any distance.
Pain prevents me walking more than 1 mile.
Pain prevents me walking more than 1/2 of a mile.
Pain prevents me walking more than 100 yards.
I can only walk using a cane or crutches.
I am in bed most of the time.
Quality of Life Questions
Section 1-Personal Care (washing, dressing, etc.)
I can look after myself normally without causing extra pain.
I can look after myself normally but it causes extra pain.
It is painful to look after myself and I am slow and careful.
I need some help but manage most of my personal care.
I need help every day in most aspects of self-care.
I do not get dressed, wash with difficulty, and stay in bed.
My sleep is never disturbed by pain.
My sleep is occasionally disturbed by pain.
Because of pain, I have less than 6 hours of sleep.
Because of pain, I have less than 4 hours of sleep.
Because of pain, I have less than 2 hours of sleep.
Pain prevents me from sleeping at all.
Section 3-Social Life
My social life is normal and causes no extra pain.
My social life is normal but increases the degree of pain.
Pain has no significant effect on my social life apart from limiting my more energetic interests, i.e. sports.
Pain has restricted my social life and I do not go out as often.
Pain has restricted my social life to my home.
I have no social life because of pain.
My normal home/job activities do not cause pain.
My normal home/job activities increase my pain, but do not prevent me from completing my tasks.
I can perform most of my home/job duties, but pain prevents me from doing more physically stressful activities (lifting/vacuuming).
Pain prevents me from doing anything but light duties.
Pain prevents me from doing even light duties.
Pain prevents me from doing any home/job activities.
I can travel anywhere without pain.
I can travel anywhere but it gives extra pain.
Pain is bad but I manage journeys of over two hours.
Pain restricts me to journeys of less than 1 hour.
Pain restricts me to short necessary journeys under 30 minutes.
Pain prevents me from traveling except to receive treatment.
Over the past 3 months have you received treatment, tablets, or medicines of any kind for your back pain?
Please state the type of treatment you received:
Post-Operative Satisfaction Survey
Have you returned to work or your daily activities?
How many weeks after surgery did you return to work or your daily activities?
Was your return to work or daily activities within the timeframe estimated by your physician by two weeks?
Describe your occupational status:
Combination of the above
On a scale of 0 - 10 (0 being the worst and 10 being the best), how would you rate the facility? Please circle below.
Would you recommend the facility to your family and/or friends?
Should be Empty: