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Questionnaire
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Low Back Pain
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Step
1
of
2
50%
Your Name
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First
Last
Average pain level with activity?
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1-3: Mild pain, easily manageable, may be a minor discomfort, no need to take over the counter medication.
4-6: Moderate pain, noticeable and may interfere with daily activities, relief with over the counter medication.
7-9: Severe pain, difficult to tolerate, significantly impacts daily functioning, little to no relief with over the counter medication.
10/10: intolerable, extreme, “I need to go to the hospital”.
0 - No Pain
1 - Mild
2 - Mild
3 - Mild
4 - Moderate
5 - Moderate
6 - Moderate
7 - Severe
8 - Severe
9 - Severe
10 - Extreme
Is your pain the result of a traumatic injury?
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Yes
No
Type of Injury?
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A Fall
A Motor Vehicle Accident
Direct Blow
Other
Have you seen a medical provider for this problem?
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Yes
No
Have you seen a medical provider for this injury?
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Yes
No
How long have you had these symptoms?
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Less than 1 month
1 to 3 months
3 to 6 months
More than 6 months
Are you able to get any form of pain relief (not necessarily elimination of pain) with position changes or movements, ex. sitting, standing, laying on back, etc.?
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Yes
No
Have you had any recent, unexplained changes to bowel and bladder?
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Yes
No
Have you had any numbness, tingling or radiating pain in your legs?
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Yes
No
Are radiating symptoms in one or both legs?
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One Leg
Both Legs
Does radiating symptoms extend beyond the knee?
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Yes
No
Stand and bend forward towards your toes 5 times.
Then place hands on back of hips and lean backwards 5 times.
Which Felt Better?
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Bending Forward
Leaning Backwards
Have you noticed specific (ex. difficulty lifting your foot) or significant weakness in your legs since injury?
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Yes
No
Read Important Information Below
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Based on your answers to the previous questions, we recommend making an appointment with your primary care provider to rule out significant pathology that may require further intervention. If you would like to start one of our rehabilitation plans in the mean time, click below to see the one we recommend for you.
I have read and understand the recommendation being made
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