Back Disability Index
This questionaire is designed to help us better understand how your neck pain affects your ability to manage everyday Life activities. Please mark in each section the one box that applies to you. Although you may consider that two of the statements in any one section relate to you, please mark the box that most closely describes your present day situation
PAIN INTENSITY
0.I have no pain at the moment.
1. The pain is very mild at the moment
2.The pain is moderate at the moment
3. The pain is fairly severe at the moment
4.The pain is very severe at the moment
5. The pain is the worst imaginable at the moment
PERSONAL CARE
0. I can look after myself normally without causing extra pain.
1. I can look after myself normally, but it causes extra pain
2. It is painful to look after myself, and I am slow and careful
3.I need some help but manage most of my personal care.
4. I need help every day in most aspects of self -care.
5. I do not get dressed. I wash with difficulty andstay in bed.
LIFTING
0.I can lift heavy weights without causing extra pain
1. I can lift heavy weights, but it gives me extra pain
2. Pain prevents me from lifting heavy weights offthe floor but I can manage if items are convenientlypositioned, ie. on a table.
3. Pain prevents me from lifting heavy weights, but Ican manage light weights if they are convenientlypositioned.
4. I can lift only very light weights.
5. I cannot lift or carry anything at all.
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WALKING
0. Pain does not prevent me walking any distance.
1. Pain prevents me walking more than 1mile.
2.Pain prevents me walking more than 1⁄4 of a mile.
3.Pain prevents me walking more than 100 yards. .
4. I can only walk using a stick or crutches.
5. I am in bed most of the time and have to crawl to the toilet.
WORKING
0. I can do as much work as I want."
1. I can only do my usual work, but no more.
2." I can do most of my usual work, but no more
3. I can't do my usual work.
4. I can hardly do any work at all.
5.I can't do any work at all.
SITTING
0. I can sit in any chair as long as I like.
1. I can sit in my favorite chair as long as I like
2. Pain prevents me from sitting for more than 1 hour.
3. Pain prevents me from sitting for more than 1⁄2 hour
4.Pain prevents me from sitting for more than 10minutes.
5. Pain prevents me from sitting at all.
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STANDING
0. I can stand as long as I want without extra pain.
1. I can stand as long as I want but it gives me extra pain.
2. Pain prevents me from standing more than 1 hour.
3. Pain prevents me from standing for more than 1⁄2 an hour.
4. Pain prevents me from standing for more than 10 minutes.
5.Pain prevents me from standing at all.
SLEEPING
0. I have no trouble sleeping
1. My sleep is slightly disturbed for less than 1 hour
2. My sleep is mildly disturbed for up to 1-2 hours
3. My sleep is moderately disturbed for up to 2-3 hours
4. My sleep is greatly disturbed for up to 3-5 hours My sleep is completely disturbed for up to 5-7 hours.
5. My sleep is greatly disturbed for up to 3-5 hours My sleep is completely disturbed for up to 5-7 hours.
DRIVING /TRAVELLING
0. I can travel anywhere without pain
1. I can travel anywhere but it gives extra pain
2. Pain is bad but I manage journeys of over two hours
3. Pain is bad and restricts me to journey's under two hours
4. Pain restricts me to short necessary journeys under 30 minutes.
Pain prevents me from traveling except to receive treatment.
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Sex life (if applicable)
0. My sex life is normal and causes no extra pain.
1. My sex life is normal but causes some extra pain.
2. My sex life is nearly normal but is very painful.
3.My sex life is severely restricted by pain.
4. My sex life is nearly absent because of pain.
5. Pain prevents any sex life at all.
RECREATION
0. I have no back pain during all recreational activities
1. I have some back pain with all recreational activities
2. I have someback pain with a few recreational activities
3. I have back pain with most recreational activities
4. I can hardly do recreational activities due to back pain
5. I can't do any recreational activities due to backpain.
SOCIAL LIFE Pain has restricted social life to my home. I have no social life because of pain.
0. My social life is normal and cause me no extra pain
1. . My social life is normal but increases the degree of pain.
2. Pain has no significant effect on my social life apart from limiting my more energetic interests, i.e. sports.
3. Pain has restricted my social life and I do not go out as often.
4. Pain has restricted social life to my home.
5. I have no social life because of pain.
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Previous Treatment: Over the past three months have you received treatment, tablets or medicines of any kind for your back or leg pain? Please check the appropriate box. No Yes (if yes, please state the type of treatment you have received)
Yes
No
If yes to previous treatment, please state the type of treatment you have received
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