coykendallchiropractic - First of the year form

Please read: This quesIonnaire is designed to enable us to understand how much your low back pain has affected your ability to manage your everyday acIviIes. Please answer each secIon by selecting the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE, JUST SELECT THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.

SECTION 1 - Pain Intensity *

The pain comes and goes and is very mild.The pain is mild and does not vary much.The pain comes and goes and is moderate.The pain is moderate and does not vary much.The pain comes and goes and is severe.The pain is severe and does not vary much.

SECTION 2 - Personal Care *

I do not have to change my way of washing or dressing in order to avoid pain.I do not normally change my way of washing or dressing even though it causes some pain.Washing and dressing increases the pain but I manage not to change my way of doing it.Washing and dressing increases the pain and I find it necessary to change my way of doing it.Because of the pain I am unable to do some washing and dressing without help.Because of the pain I am unable to do any washing and dressing without help.

SECTION 3 - Lifting *

I can lil heavy weights without extra pain.I can lil heavy weights but it causes extra pain.Pain prevents me from lifting heavy weights off the floor.Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g., on a table.Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.I can only lil very light weights at the most.

SECTION 4 - Walking *

I have no pain on walking.I have some pain on walking but it does not increase with distance.I cannot walk more than one mile without increasing pain.I cannot walk more than 1/2 mile without increasing pain.I cannot walk more than 1/4 mile without increasing pain.I cannot walk at all without increasing pain.

SECTION 5 - Sitting *

I can sit in any chair as long as I like.I can sit only in my favorite chair as long as I like.Pain prevents me from sitting more than one hour.Pain prevents me from sitting more than 1/2 hour.Pain prevents me from sitting more than 10 minutes.I avoid sitting because it increases pain straight away.

SECTION 6 - Standing *

I can stand as long as I want without pain.I have some pain on standing but it does not increase with Ime.I cannot stand for longer than one hour without increasing pain.I cannot stand for longer than 1/2 hour without increasing pain.I cannot stand for longer than 10 minutes without increasing pain.I avoid standing because it increases the pain immediately.

SECTION 7 - Sleeping *

I get no pain in bed.I get pain in bed but it does not prevent me from sleeping well.Because of pain my normal night’s sleep is reduced by less than 1/4.Because of pain my normal night’s sleep is reduced by less than 1/2.Because of pain my normal night’s sleep is reduced by less than 3/4.Pain prevents me from sleeping at all.

SECTION 8 - Social Life *

My social life is normal and gives me no pain.My social life is normal but increases the degree of my pain.Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc.Pain has restricted my social life, and I do not go out very often.Pain has restricted my social life to my home.I have hardly any social life because of the pain.

SECTION 9 - Travel *

I get no pain while traveling.I get some pain while traveling, but none of my usual forms of travel make it any worse.I get extra pain while traveling, but it does not compel me to seek alternative forms of travel.I get extra pain while traveling, which compels me to seek alternative forms of travel.Pain restricts all forms of travel.Pain prevents all forms of travel except that done lying down

SECTION 10 - Changing degree of pain *

My pain is rapidly getting better.My pain fluctuates but overall is definitely getting better.My pain seems to be getting better but improvement is slow at present.My pain is neither getting better nor worse.My pain is gradually worsening.My pain is rapidly worsening.

Disability Index Score:

Signature of Patient, Parent or Legal Guardian (if a minor)*

Date:*

Date

Name:

First NameLast Name

Date:

Date

Age:

Date of Birth:

Date

Occupation:

How long have you had low back pain?

YearsMonthsWeeks

How many {howLong45}?

Is this your first episode of your low back pain?

YesNo

First of the year form - LOW BACK

PATIENT INFORMATION

REASON FOR VISIT

THE REVISED OSWESTRY LOW BACK PAIN QUESTIONNAIRE