LOW BACK PAIN AND DISABILITY QUESTIONNAIRE SOFTWARE

Name:____________________

Ref. Dr:___________________

Date: _______

ID#: _______________

Age: _______

Gender: M / F

Please read:
When your back hurts, you may find it difficult to do some of the things you normally do. Mark only the sentences that describe you today.

1. I stay at home most of the time because of my back.
2. I change position frequently to try and get my back comfortable.
3. I walk more slowly than usual because of my back.
4. Because of my back, I am not doing any jobs that I usually do around the house.
5. Because of my back, I use a handrail to get upstairs.
6. Because of my back, I lie down to rest more often.
7. Because of my back, I have to hold on to something to get out of an easy chair.
8. Because of my back, I try to get other people to do things for me.
9. I get dressed more slowly than usual because of my back.
10. I stand up only for short periods of time because of my back.
11. Because of my back, I try not to bend or kneel down.
12. I find it difficult to get out of a chair because of my back.
13. My back is painful almost all of the time.
14. I find it difficult to turn over in bed because of my back.
15. My appetite is not very good because of my back.
16. I have trouble putting on my socks (or stockings) because of pain in my back.
17. I walk only short distances because of my back pain.
18. I sleep less well because of my back.
19. Because of back pain, I get dressed with help from someone else.
20. I sit down for most of the day because of my back.
21. I avoid heavy jobs around the house because of my back.
22. Because of back pain, I am more irritable and bad tempered with people than usual.
23. Because of my back, I go up stairs more slowly than usual.
24. I stay in bed most of the time because of my back.