Back Pain Questionnaire

Back Pain Questionnaire
Name*
Age*
Occupation*
How frequent is your back pain?*

SometimesMost of the timeConstant
Back pain intensity
Worst Number*   /10
Best Number*   /10
On average Number*   /10
Leg pain intensity
Worst *   /10
Best *   /10
On average *   /10

Please tick the characteristic of your pain and draw or shade the pain area in the cartoon below:

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Numbness
Pins and needles
Burning pain
Stabbing pain
Aching pain

Is your pain as a result of an injury?*

YesNo
(If Work cover or Motor accident claim please fill up the accompanying injury form) Otherwise Please describe the injury here:
Have you had pain before? If yes, please describe the-duration, number of episodes, treatments and their effectiveness?
Which activities aggravates the pain?*
Do you feel weakness in the legs or feet ?*

YesNo
If yes please describe the weakness
How long can you walk for?*
Do you find leaning on a trolley, walking frame or walking stick makes things easier?*

YesNo
Do you have to sit down to make the pain better?*

YesNo
What’s worse, Back or Leg pain:
Back pain percentage (%)*
Leg pain percentage (%)*
Are you having any bowel or bladder problems related to your pain?*

YesNo
Are you able to drive?*

YesNo
Are you able to look after yourself?*

YesNo
Are you able to work?*

YesNo
Are you recreational activities being affected?*

YesNo
Which activities are most affected
Is your problem getting:*

BetterWorseStaying same
Do you have problems in any other joint?*

YesNo
If Yes, has it been diagnosed Rheumatoid , Osteoarthritis or some other named disease? Which other Joints are involved?
Have you lost appetite recently? *

YesNo
Have lost weight recently? *

YesNo
How much? Is it intentional or unexplained?
Have you lost appetite recently? *

YesNo
Are you having fevers, hot sweats or chills?*

YesNo
Have you been diagnosed or treated for any cancer? *

YesNo
If yes, please summarise or tell me during the consultation
What pain medications do you take? How long have you been taking these? What treatments have you tried so far? *
Do you think or have you been told you need surgery?*

YesNo
Have you had any spine surgery before?*

YesNo
Please describe if you know what was the surgery?*
Is there any legal case pending?*

YesNo
Do you smoke?*

YesNo
How long you have been smoking and how many you smoke per day ?
Do you drink alcohol?*

YesNo
If yes, how many standard drinks per week?
What level of physical fitness activities do you do?*
What’s the reason for making this appointment?*

GP advise the specialist opinionYou wanted to see a specialist and learn more about the cause and management of the pain.You have been advised surgery but you would like to discuss the other optionsYou have tried everything else and would like to discuss and consider whether surgery is indicated or not
Is there anything special you would like to discuss or ask today? *
Signature*

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Back Pain Questionnaire

What’s worse, Back or Leg pain: