EmailMe Form - Low Back Pain Questionnaire

Today's Date
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Name
First MI Last
#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.
#2 Personal Care (Washing/Dressing, etc.)
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 pain, I am unable to do SOME washing and dressing without help.
Because of pain, I am unable to do ANY washing and dressing without help.
#3 Lifting
I can lift heavy weights WITHOUT extra pain.
I can lift 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 weights, but I can manage LIGHT TO MEDIUM weights if they are conveniently positioned,
I can only life very light weights at the most.
#4 Walking
I have no pain when walking.
I have SOME pain with waking, but it does not increase with distance.
I cannot walk more than 1 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.
#5 Sitting
I can sit in any chair as long as I like without pain.
I can sit ONLY in my FAVORITE chair as long as I like.
Pain prevents me from sitting more than 1 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 immediately.
#6 Standing
I can stand as long as I want without pain.
I have some pain standing, but it does not increase with time.
I cannot stand for longer than 1 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.
#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.
#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 y more energetic interest, e.g. dancing.
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 my pain.
#9 Traveling
I get no pain while traveling.
I get some pain while traveling, but none of my usual forms of travel make it 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 does compel me to seek alternative forms of travel
Pain restricts all forms of travel.
Pain prevents all forms of travel except that done lying down.
#10 Changing Degrees 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 paid is gradually worsening.
My pain is rapidly worsening.
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