Low Back Questionnaire

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1. How bad is your back pain?* This field is required.How bad is the Pain? (0/10 = no pain, 10/10 = take me to hospital)
4/10 No pain medication is needed
5/10 Still no pain medication is needed
6/10 Pain medication gives me relief
7/10 Pain medication gives me moderate relief
8/10 Pain medication gives me little relief
10/10 Pain medication gives no relief
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2. Personal care (washing, dishes, dressing etc)* This field is required.How bad is the Pain? (0/10 = no pain, 10/10 = take me to hospital)
I look after myself normally without causing extra pain
I can look after normally, but it causes extra pain
It is painful to look after myself and I am slow and careful
I need some help but I can manage most of my personal care
I need help everyday in most aspects of self care
I do not get dressed or wash by myself, and need help getting out of bed
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3. How do you feel when lifting?* This field is required.
I can lift heavy weights with no pain
I can lift heavy weights normally, but it causes extra pain
It is too painful to lift things off the floor, but can manage if they are conveniently placed, eg. on a table
I can lift light to medium weights if they are conveniently positioned
I can only lift very light weights
I cannot lift or carry anything
4
4. How do you feel walking?* This field is required.
I can walk any distance without pain
Pain prevents me walking more than 2 km
Pain prevents me walking more than 1 km
Pain prevents me walking more than 200m
I can only walk with a stick or crutches
I'm need to be in bed most of the time
5
5. How do you feel sitting?* This field is required.
I can sit in any chair as long as I like
I can sit in my favourite chair as long as I like
Pain prevents me from sitting for more than 1 hour
Pain prevents me from sitting for more than 30 minutes
Pain prevents me from sitting more than 10 minutes
Pain prevents me from sitting at all
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6. How do you feel standing?* This field is required.
I can stand as long as I like
I can stand as long as I want but it gives me pain
Pain prevents me from standing for more than 1 hour
Pain prevents me from standing for more than 30 minutes
Pain prevents me from standing for more than 10 minutes
Pain prevents me from standing at all
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7. How well do you sleep?* This field is required.
I can sleep comfortably
My sleep is slightly disturbed (less that 1 hour sleepless)
My sleep is mildly disturbed (1-2 hours sleepless)
My sleep is moderately disturbed (2-3 hours sleepless)
My sleep is greatly disturbed (3-5 hours sleepless)
My sleep is completely disturbed (5-7 hours sleepless)
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8. How is your social life affected by your back pain?* This field is required.
My social life is normal and gives me 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, eg. sport
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 my pain
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9. How does your back pain affect travelling?* This field is required.
I can travel anywhere without pain
I can travel anywhere but it gives me extra pain
Pain is bad but I manage journeys more than 2 hours
Pain restricts me to journeys of less than 1 hour
Pain restricts me to short, necessary journeys less than 30 minutes
Pain prevents me from travelling except to receive treatment
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10. How does your back pain affect your work & home life?* This field is required.
My normal work/home activities do not cause pain
My normal work/home activities increase my pain, but I can still perform all that is required of me
My normal work/home activities are possible but pain prevents me from performing more physically stressful activities (eg. vacuuming, lifting)
Pain prevents me from doing anything but light duties
Pain prevents me from doing even light duties
Pain prevents me from doing any work or home chores
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Full Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Area Code
Phone Number
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email* This field is required.
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