Low Back Disability Form DATE Name Email Address Best Contact Phone Number File Number This questionnaire helps us to understand how much your low back pain has affected your ability to perform everyday activities. Please check the one box in each section that most clearly descripbes your problem right now. SECTION 1 PAIN LEVELS The pain comes and goes and is very mild The pain is mild and does not vary much. The pain comes and goes increases with time, 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. SECTION 2 PERSONAL CARE I would 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 increase the pain and I find it necessary to change my way of doing it. Washing and dressing increase the pain but I manage not 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 and dressing without help. SECTION 3 LIFTING I can lift heavy weights without extra pain I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weight off the floor. Pain prevents me from lifting heavy weight off the floor, but I can manage if they are conveniently positioned, e.g. on a table. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can only lift very light weights at the most. SECTION 4 WALKING I have no pain on walking I have some pain on walking but it does not increase with distance. 1 cannot walk more than one 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 SECTION 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 for more than 10 minutes. I avoid sitting because it increases pain immediately. SECTION 6 STANDING I can stand as long as I want without pain. I have some pain on standing, but it does not, increase with time. I cannot stand for longer than one 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. SECTION 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 sleep is reduced by less than 3/4 Pain prevents me from sleeping at all. SECTION 8 SOCIAL LIFE My social life is normal and gives me no pain. My social life is normal, but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc. 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. 1 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 is rapidly getting better. My pain fluctuates, but overall is definitely getting better. My pain seems to be getting better, but improvement is slow. My pain is neither getting better nor getting worse. My pain is gradually worsening. My pain is rapidly worsening. SUBMIT Please do not submit any Protected Health Information (PHI). Contact Us With Questions
