1st Place Chiropractic - Low Back Disability Questionnaire

This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please mark the box which MOST CLOSELY describes your problem.

Section 1 - Pain Intensity*

I can tolerate the pain without having to use painkillers.The pain is bad but I can manage without taking painkillers.Painkillers give complete relief from pain.Painkillers give moderate relief from pain.Painkillers give very little relief from pain.Painkillers 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 every day in most aspects of self care.I do not get dressed, I 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, for example on a table.Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.I can life 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 one mile.Pain prevents me from walking more than one-half mile.Pain prevents me from walking more than one-quarter mile.I can only walk using a stick or crutches.I am in bed most of the time and have to crawl to the toliet.

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 more than one hour.Pain prevents me from sitting more than 30 minutes.Pain prevents me from sitting more than 10 minutes.Pain prevents me from sitting almost all the time.

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 more than 1 hour.Pain prevents me from standing more than 30 minutes.Pain prevents me from standing 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 6 hours sleep.Even when I take tablets I have less than 4 hours sleep.Even when I take tablets I have less than 2 hours sleep.Pain prevents me from sleeping at all.

Section 8 - 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.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 9 - Traveling*

I can travel anywhere without extra pain.I can travel anywhere but it gives me extra pain.Pain is bad but I manage journeys over 2 hours.Pain is bad but I manage journeys less than 1 hour.Pain restricts me to short necessary journeys under 30 minutes.Pain prevents me from traveling except to the doctor or hospital.

Section 10 - Changing Degree of Pain*

My pain is rapidly getting better.My pain fluctuates but overall is definitely getting better.My pain seems to be getting better but improvement is slow at the present.My pain is neither better better nor worse.My pain is gradually worsening.My pain is rapidly worsening.

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