SRS-22r
SPINAL DEFORMITY QUESTIONNAIRE
Date
*
-
Month
-
Day
Year
Date
Enter Your Initials
*
Function
Pain
Self-Image
Mental Health
Management
Total Score
% Impaired
INSTRUCTIONS: We are carefully evaluating the condition of your back and it is IMPORTANT THAT YOU ANSWER EACH OF THESE QUESTIONS YOURSELF. Please SELECT THE BEST ANSWER TO EACH QUESTION.
1. Which one of the following best describes the amount of pain you have experienced during the past 6 months?
*
a. Severe
b. Moderate to severe
c. Moderate
d. Mild
e. None
2. Which one of the following best describes the amount of pain you have experienced over the last month?
*
a. Severe
b. Moderate to severe
c. Moderate
d. Mild
e. None
3. During the past 6 months have you been a very nervous person?
*
a. All of the time
b. Most of the time
c. Some of the time
d. A little of the time
e. None of the time
4. If you had to spend the rest of your life with your back shape as it is right now, how would you feel about it?
*
a. Very unhappy
b. Somewhat unhappy
c. Neither happy nor unhappy
d. Somewhat happy
e. Very happy
5. What is your current level of activity?
*
a. Bedridden
b. Primarily no activity
c. Light labor and light sports
d. Moderate labor and moderate sports
e. Full activities without restriction
6. How do you look in clothes?
*
a. Very bad
b. Bad
c. Fair
d. Good
e. Very good
7. In the past 6 months have you felt so down in the dumps that nothing could cheer you up?
*
a. Very often
b. Often
c. Sometimes
d. Rarely
e. Never
8. Do you experience back pain when at rest?
*
a. Very often
b. Often
c. Sometimes
d. Rarely
e. Never
9. What is your current level of work/school activity?
*
a. 0% normal
b. 25% normal
c. 50% normal
d. 75% normal
e. 100% normal
10. Which of the following best describes the appearance of your trunk; defined as the human body except for the head and extremities?
*
a. Very poor
b. Poor
c. Fair
d. Good
e. Very Good
11. Which one of the following best describes your pain medication use for back pain?
*
a. Narcotics daily
b. Narcotics weekly or less (e.g. Tylenol III, Lorcet, Percocet)
c. Non-narcotics daily
d. Non-narcotics weekly or less (e.g., aspirin, Tylenol, Ibuprofen)
e. None
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12. Does your back limit your ability to do things around the house?
*
a. Very Often
b. Often
c. Sometimes
d. Rarely
e. Never
13. Have you felt calm and peaceful during the past 6 months?
*
a. None of the time
b. A little of the time
c. Some of the time
d. Most of the time
e. All of the time
14. Do you feel that your back condition affects your personal relationships?
*
a. Severely
b. Moderately
c. Mildly
d. Slightly
e. None
15. Are you and/or your family experiencing financial difficulties because of your back?
*
a. Severely
b. Moderately
c. Mildly
d. Slightly
e. None
16. In the past 6 months have you felt down hearted and blue?
*
a. Very Often
b. Often
c. Sometimes
d. Rarely
e. Never
17. In the last 3 months have you taken any days off of work, including household work, or school because of back pain?
*
a. 4 day or more days
b. 3 day
c. 2 days
d. 1 days
e. 0 days
18. Does your back condition limit your going out with friends/family?
*
a. Very Often
b. Often
c. Sometimes
d. Rarely
e. Never
19. Do you feel attractive with your current back condition?
*
a. No, not at all
b. No, not very much
c. Neither attractive nor unattractive
d. Yes, somewhat
e. Yes, very
20. Have you been a happy person during the past 6 months?
*
a. None of the time
b. A little of the time
c. Some of the time
d. Most of the time
e. All of the time
21. Are you satisfied with the results of your back management?
*
a. Very unsatisfied
b. Unsatisfied
c. Neither satisfied nor unsatisfied
d. Satisfied
e. Very satisfied
22. Would you have the same management again if you had the same condition?
*
a. Definitely not
b. Probably not
c. Not sure
d. Probably yes
e. Definitely yes
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