Dr. McElroy Lumbar Questionnaire

Dr. McElroy Lumbar Questionnaire
This questionnaire is designed to enabled us to understand how much your low back pain has affected your ability to manage everyday activities.
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Date of Appointment *

Month Day Year
Date
Time of Appointment *

: Hour Minutes AM/PM Option
Please answer each question by choosing the ONE choice that most applies to you. We realize that you may feel more than one statement relates to you, but you should choose the statement which best describes your problem right now.
Pain Intensity *
Personal Care (washing, dressing, etc) *
Lifting *
Walking *
Sitting *
Standing *
Sleeping *
Social Life *
Traveling *
Changing Degree of Pain *
Patient signature *

Clear
Should be Empty: