How long have you had back pain? _____ Years _____ Months _____ Weeks
How long have you had leg pain? _____ Years _____ Months _____ Weeks
Please read:
This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in every day life. Please answer every section, and mark in each section only the one box that applies to you. We realize you may consider that two of the statements in any one section may relate to you, but please just mark the box which most closely describes your problem.
Section 1- Pain Intensity
I can tolerate the pain I have without having to use pain killers.
The pain is bad but I manage without taking pain killers.
Pain killers give complete relief from pain.
Pain killers give moderate relief from pain.
Pain killers give very little relief from pain.
Pain killers have no effect on the pain and I do not use them.
Section 2- Personal Care (Washing, Dressing, etc.)
I can look after myself normally without causing extra pain.
I can look after myself normally but it causes extra pain.
It is painful to look after myself and I am slow and careful.
I need some help but manage most of my personal care.
I need help everyday in most aspects of self care.
I do not get dressed, wash with difficulty and stay in bed.
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 weights off the floor, but I can manage if they are conveniently positioned, e.g., on table.
Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned.
I can lift only very light weights.
I cannot lift or carry anything at all.
Section 4- Walking
Pain does not prevent me from walking any distance.
Pain prevents me from walking more than 1 mile.
Pain prevents me from walking more than 1/2 mile.
Pain prevents me from walking more than 1/4 mile.
I can only walk using a stick or crutches.
I am in bed most of the time and have to crawl to the toilet.
Section 5- Sitting
I can sit in any chair as long as I like.
I can only sit in my favorite chair as long as I like.
Pain prevents me from sitting for more than 1 hour.
Pain prevents me from sitting for more than 1/2 hour.
Pain prevents me from sitting for more than 10 minutes.
Pain prevents me from sitting at all.
Section 6- Standing
I can stand as long as I want without extra pain.
I can stand as long as I want but it gives me extra pain.
Pain prevents me from standing for more than 1 hour.
Pain prevents me from standing for more than 30 minutes.
Pain prevents me from standing for more than 10 minutes.
Pain prevents me from standing at all.
Section 7- Sleeping
Pain does not prevent me from sleeping well.
I can sleep well only by using tablets.
Even when I take tablets I have less than six hours sleep.
Even when I take tablets I have less than four hours sleep.
Even when I take tablets I have less than two hours sleep.
Pain prevents me from sleeping at all.
Section 8- Sex Life
My sex life is normal and causes no extra pain.
My sex life is normal and causes some extra pain.
My sex life is nearly normal but is very painful.
My sex life is severely restricted by pain.
My sex life is nearly absent because of pain.
Pain prevents any sex life at all.
Section 9- Social Life
My social life is normal and gives me no extra 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 as often.
Pain has restricted my social life to my home.
I have no social life because of pain.
Section 10- Traveling
I can travel anywhere without extra pain.
I can travel anywhere but it gives me extra pain.
Pain is bad but I can manage journeys over two hours.
Pain restricts me to journeys of less than one hour.
Pain restricts me to short necessary journeys under 30 minutes.
Pain prevents me from traveling except to the doctor or the hospital.