Lower Back Pain Quiz

1
How bad is the Pain? (0/10 = no pain, 10/10 = take me to hospital)* This field is required.
4/10 no pain medication needed
5/10 but still no pain medication needed
6/10 Pain medication gives me relief
7/10 Pain medication gives moderate relief
8/10, Pain medication gives a little relief
10/10, Pain medication has no effect
2
How does your back cope with everyday activities? (e.g., Washing, Dressing)* This field is required.
Normal, no extra pain
Normal, but it increases my pain
I am slow and careful but independent
I need help with some things
I need help every day
I do not get dressed and stay in bed
3
How does your lower back feel when lifting?* This field is required.
I can lift heavy weights without increased pain
I can lift heavy weights, but it increases pain
Pain means I can’t lift heavy weights off the floor
Pain, can’t lift heavy weights, can sometimes lift moderate weight
I can lift only very light weights
I can not lift or carry anything at all
4
How does your lower back feel when walking?* This field is required.
Can still walk any distance with pain
Pain prevents me from walking more than 1km
Pain prevents me from walking more than ½ km
Pain prevents me from walking more than ¼ km
I can walk only with crutches or a cane
I am in bed most of the time
5
How does your lower back feel when sitting?* This field is required.
I can sit in any chair as long as I like
I can sit in my favourite chair for as long as I like
Pain prevents me from sitting for more than 1 hour
Pain prevents me from sitting for more than ½ an hour
Pain prevents me from sitting for more that 10 minutes
Pain prevents me from sitting at all
6
How does your lower back pain feel when standing?* This field is required.
I can stand as long as I want without increased pain
I can stand as long as I want but it increases my pain
Pain prevents me from standing for more than 1 hour
Pain prevents me from standing for more than ½ an hour
Pain prevents me from standing for more than 10 minutes
Pain prevents me from standing at all
7
How does your Lower Back Pain affect your sleep?* This field is required.
My sleep is never disturbed by pain
I can sleep well only using pain medication
Even when I take medication, I sleep less than 6 hours
Even when I take medication, I sleep less than 4 hours
Even when I take medication, I sleep less than 2 hours
Pain prevents me from sleeping at all
8
How is your social life affected by your lower back pain?* This field is required.
My social life is normal and does not increase my pain
My social life is normal, but it increases my level of pain
Pain prevents me from participating in High Intensity
Pain prevents me from going out very often
Pain has restricted my social life to my home
I have hardly any social life because of my pain
9
How does your lower back pain affect traveling?* This field is required.
I can travel anywhere without increased pain
I can travel anywhere, but it increases my pain
My pain restricts my travel over 2 hours
My pain restricts my travel over 1 hour
My pain restricts my travel to under 1/2 hour
My pain prevents all travel except to the doctor/therapist or hospital
10
How much does your Lower Back Pain affect your employment/jobs at home* This field is required.
My normal job/activities do not cause pain
My normal job/activities increases my pain, but I still do it
I can perform most duties, but pain prevents me from more physical activities
Pain prevents me from doing anything but light duties
Pain prevents me from doing even light duties
Pain prevents me from performing any jobs
11
Name* This field is required.Enter your details to get your results
First Name
Last Name
12
Email* This field is required.
example@example.com
13
Mobile Phone* This field is required.
14
Old Mobile Phone* This field is required.We will SMS your results to this number
15
Score
Should be Empty: