Patient name
*
Date
*
/
Month
/
Day
Year
Date
Has your back pain spread down your leg(s) at some time in the last 2 weeks?
*
No
Yes
Have you had pain in the shoulder or neck at some time in the last 2 weeks?
*
No
Yes
Have you only walked short distances because of your back pain?
*
No
Yes
In the last 2 weeks, have you dressed more slowly than usual because of back pain?
*
No
Yes
Do you think it's not really safe for a person with a condition like yours to be physically active?
*
No
Yes
Have worrying thoughts been going through your mind a lot of the time?
*
No
Yes
Do you feel that your back pain is terrible and it's never going to get any better?
*
No
Yes
In general have you stopped enjoying all the things you usually enjoy?
*
No
Yes
Overall, how bothersome has your back pain been in the last 2 weeks?
*
Not at all
Slightly
Moderately
Very Much
Extremely
Preview PDF
Submit
Should be Empty: