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 pain medication needed
5/10 but still no pain medication 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 has no relief
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 only walk with crutches or cranes.
I'm 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 hour.
Pain prevents me from sitting for more than 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 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?
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 travelling?* 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 ½ 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 increase my pain, but I still do it.
I can perform most duties, but pain prevents me from doing 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
Your Information* This field is required.
Should be Empty: