Back Pain Questionnaire

  1. In the past 10 days, have you suffered from pain in your lower back? Y     N

If yes, how many days out of the past 10 days have you suffered from back pain?   1     2     3    4    5+

 

  1. In the past 10 days, have you had trouble falling asleep, had difficulty staying asleep, or altered your position for sleep (sitting up, reclining rather than lying down, etc.)? Y    N

If yes, how many nights out of the past 10 have you had issues with your sleep?   1   2   3   4   5+

 

  1. In the past 10 days, have you taken more than 2 doses of medication for your back pain (prescription or OTC medications)? Y    N

If yes, how many days out of the past 10 days how many doses of medication have you taken?  1   2   3   4   5+

 

  1. In the past 10 days, have you had difficulty performing your work duties or, if retired, doing household chores or other activities? Y   N

If yes, how many days have you had difficulty performing work or other duties?    1   2   3   4   5+

 

  1. In the past 10 days, have you had back pain when getting in or out of bed? Y   N

If yes, how many days have you had pain when getting in or out of bed?   1   2   3   4   5+

 

  1. In the past 10 days, have you had back pain when putting on or tying your shoes? Y   N

If yes, how many days have you had pain when putting on or tying your shoes?    1   2   3   4   5+

 

  1. In the past 10 days, have you had back pain when sitting or standing for 30 minutes or less? Y   N

If yes, how many days have you had pain when sitting or standing for 30 minutes or less?   1   2   3   4   5+

 

  1. In the past 10 days, have you avoided recreational or usual activities fearing that your back pain might increase? Y   N

If yes, how many activities have you avoided that you would have liked to perform if you didn’t worry about the potential of increased back pain?     1   2   3   4   5+

 

  1. In the past 10 days, have you had increased pain driving your car or traveling? Y  N

If yes, how many days have you had increased pain while traveling or driving?  1   2   3   4   5+

 

  1. In the past year, have you noticed that your back pain has worsened or become more intense?   Y  N

If yes, on a scale of 1 to 5 (1 being a slight increase up to 5 being a great increase in pain intensity), rate your level of increased pain and discomfort due to you back pain symptoms worsening.    1   2   3   4   5

Scoring:  add up the numbers that you have rated your yes responses:  example 1= 1; 2 = 2; 3 = 3; 4 = 4; 5+ = 5
If you scored more than 10 points, please contact us for a consult for physical therapy.

 

Mike Pennington

Mike Pennington

Michael Pennington is a physical therapist and the owner of Turning Point Physical Therapy, which is located in beautiful southern Oregon. He is a loving husband, father of six and a master of his trade. Before studying at Pacific University, Michael earned his Eagle Scout and served a full-time 2 year mission in south Africa. He is as accomplished as he is hard working. Al l of his experiences culminate together at his clinic and are evident in his patient care.
Mike Pennington

We Help People in Medford, Ashland, Grants Pass, Klamath Falls, Yreka Areas Aged 40+ Become More Active And Mobile, Live Free From Painkillers and Surgery!

 

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