LOW BACK

Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability. Please choose the answers below that best apply.

Please rate your pain level with activity:

NO PAIN = 012345678910 = VERY SEVERE PAIN


1. Pain Intensity
0. I can tolerate pain I have without having to use pain medication.

1. The pain is bad, but I can manage without having to take pain medication.

2. Pain medication provides me with complete relief from pain

3. Pain medication provides me with moderate relief from pain

4. Pain medication provides me with little relief from pain

5. Pain medication has no effect on my pain
 
2. Personal Care (washing, dressing, etc.)
0. I can tolerate pain I have without having to use pain medication.

1. The pain is bad, but I can manage without having to take pain medication.

2. Pain medication provides me with complete relief from pain

3. Pain medication provides me with moderate relief from pain

4. Pain medication provides me with little relief from pain

5. Pain medication has no effect on my pain
 
3. Lifting
0. I can tolerate pain I have without having to use pain medication.

1. The pain is bad, but I can manage without having to take pain medication.

2. Pain medication provides me with complete relief from pain

3. Pain medication provides me with moderate relief from pain

4. Pain medication provides me with little relief from pain

5. Pain medication has no effect on my pain
 
4. Walking
0. I can tolerate pain I have without having to use pain medication.

1. The pain is bad, but I can manage without having to take pain medication.

2. Pain medication provides me with complete relief from pain

3. Pain medication provides me with moderate relief from pain

4. Pain medication provides me with little relief from pain

5. Pain medication has no effect on my pain
 
5. Sitting
0. I can tolerate pain I have without having to use pain medication.

1. The pain is bad, but I can manage without having to take pain medication.

2. Pain medication provides me with complete relief from pain

3. Pain medication provides me with moderate relief from pain

4. Pain medication provides me with little relief from pain

5. Pain medication has no effect on my pain
 
6. Standing
0. I can tolerate pain I have without having to use pain medication.

1. The pain is bad, but I can manage without having to take pain medication.

2. Pain medication provides me with complete relief from pain

3. Pain medication provides me with moderate relief from pain

4. Pain medication provides me with little relief from pain

5. Pain medication has no effect on my pain
 
7. Sleeping
0. I can tolerate pain I have without having to use pain medication.

1. The pain is bad, but I can manage without having to take pain medication.

2. Pain medication provides me with complete relief from pain

3. Pain medication provides me with moderate relief from pain

4. Pain medication provides me with little relief from pain

5. Pain medication has no effect on my pain
 
8. Social Life










 
9. Traveling
0. I can tolerate pain I have without having to use pain medication.

1. The pain is bad, but I can manage without having to take pain medication.

2. Pain medication provides me with complete relief from pain

3. Pain medication provides me with moderate relief from pain

4. Pain medication provides me with little relief from pain

5. Pain medication has no effect on my pain
 
10. Employment / Homemaking
0. I can tolerate pain I have without having to use pain medication.

1. The pain is bad, but I can manage without having to take pain medication.

2. Pain medication provides me with complete relief from pain

3. Pain medication provides me with moderate relief from pain

4. Pain medication provides me with little relief from pain

5. Pain medication has no effect on my pain