LOW BACK PAIN AND DISABILITY QUESTIONNAIRE

Name: ________________		Date: ____/___/_____

Doctor: _______________

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. qI stay at home most of the time because of my back.

2. q I change position frequently to try and get my back comfortable. 

3. q I walk more slowly than usual because of my back. 

4. q Because of my back, I am not doing any jobs that I usually do around the house. 

5. q Because of my back, I use a handrail to get upstairs. 

6. q Because of my back, I lie down to rest more often. 

7. q Because of my back, I have to hold on to something to get out of an easy chair. 

8. q Because of my back, I try to get other people to do things for me. 

9. q I get dressed more slowly than usual because of my back. 

10. q I stand up only for short periods of time because of my back. 

11. q Because of my back, I try not to bend or kneel down. 

12. q I find it difficult to get out of a chair because of my back. 

13. q My back is painful almost all of the time. 

14. q I find it difficult to turn over in bed because of my back. 

15. q My appetite is not very good because of my back. 

16. q I have trouble putting on my socks (or stockings) because of pain in my back. 

17. q I walk only short distances because of my back pain. 

18. q I sleep less well because of my back. 

19. q Because of back pain, I get dressed with help from someone else. 

20. q I sit down for most of the day because of my back. 

21. q I avoid heavy jobs around the house because of my back. 

22. q Because of back pain, I am more irritable and bad tempered with people than usual. 

23. q Because of my back, I go up stairs more slowly than usual. 

24. q I stay in bed most of the time because of my back.