Back Pain

This questionnaire has been designed to give your therapist information as to how your back pain has affected your ability to manage in everyday life. Please answer every question by selecting the one box that best describes your condition today.

 

We realize you may feel that two of the statements may describe your condition, but please mark only the box which most closely describes your current condition.

PAIN INTENSITY

LIFTING

WALKING

SITTING

STANDING

SLEEPING

SOCIAL LIFE

TRAVELING

EMPLOYMENT/HOMEMAKING

Wordmark Vertical.png