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. All of his experiences culminate together at his clinic and are evident in his patient care.
Mike Pennington

Latest posts by Mike Pennington (see all)

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!

 

Want Some Help To Get There Faster?

Choose Which One Works Best For You...

Physical Therapy Appointments & Questions?  Call Free: 541.535.2551

© 2017 Turning Point Physical Therapy | 331 S Pacific Hwy | Talent, OR 97540 | 541.535.2551

Hours of Operation: M-F 8am–5pm