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Low Back Pain Questionnaire Form

Please Read: This questionnaire is designed to enable us to understand how much your low back/leg pain is affecting your ability to manage everyday activities. Thanks!!!

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SECTION 1 – Pain Intensity
I have no pain.The pain is mildThe pain comes and goes and is moderate.The pain does not vary much and is moderate.The pain comes and goes and is severe.The pain does not vary much and is severe

SECTION 2 - Personal Care
I would not have to change my way of washing or dressing 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 the pain, I am unable to do some washing and dressing without help.Because of the pain, I am unable to do any washing or dressing without help.

SECTION 3 – Walking
I can walk as long as I want without getting pain.Walking gives me pain which does not increase with time.Walking gives me pain which I can relieve by varying my pace.I get pain only when I walk long distances.I get pain when I walk short distancesI avoid walking because it gives me pain straight away.

SECTION 4 – Standing
I can stand as long as I want without pain.Standing eventually causes some pain, but it does not increase with time.Standing eventually gives me pain which I can relieve by shifting my weight.Standing eventually gives me pain which I can not relieve by shifting my weight.I get pain soon on standing.I avoid standing because I get pain straight away.

SECTION 5 – Sitting
I can sit in any chair as long as I like without pain.I can sit in some types of chairs as long as I like without getting pain.I get pain only when I get out of some seats.I get pain after sitting in most seats.I get pain soon on sitting in most seats.Sitting in most seats gives me pain straight away.

SECTION 6 - Sleeping
I get no pain in bed.I get some pain in bed but it does not disturb my sleep.I get some pain in bed which sometimes disturbs my sleep.I get pain in bed which often disturbs my sleep.I get pain in bed which always disturbs my sleep.Pain prevents me from sleeping at all.

SECTION 7 - 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 from any height.Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, (eg. on a table)Pain prevents me from lifting heavy weights off the floor, but I can manage medium weights if they are conveniently positioned.I can only lift very light weights at the most.

SECTION 8 - Social Life
My social life is normal and gives me no pain.My social life is normal but increases the pain.Pain has no significant effect on my social life apart from limiting more energetic interests, (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 the pain.

SECTION 9 – Traveling
I get no pain while traveling.I get some pain while traveling, but none of my usual forms of travel make it any 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 compels me to seek alternative forms of travel.Pain restricts all forms of travel.Pain prevents all forms of travel except that done lying down.

SECTION 10 - Changing Degree of Pain
My pain has gone.My pain is rapidly getting better.My pain varies but is slowly getting better.My pain is getting neither better nor worse.My pain is slowly worsening.My pain is rapidly worsening.

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