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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○○○○
∆∆∆∆
xxxx

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

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*

Date*

Please verify that you are human*

Back Pain Questionnaire

What’s worse, Back or Leg pain: