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Back Pain Self-Test

Are You Tired of Low Back Pain?
Are You Looking For Help?

This list contains some sentences that people have used to describe themselves when they have back pain.

When you read them, you may find that some stand out because they describe you today. As you read the list, think of yourself today. When you read a sentence that describes how you feel today, check the box next to it. If the sentence does not describe you, then leave the box blank and go on to the next one.

I stay home most of the time because of my back.

I change position frequently to try to get my back comfortable.

I walk more slowly than usual because of my back.

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

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

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

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

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

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

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

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

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

My back is painful almost all the time.

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

My appetite is not very good because of my back.

I have trouble putting on my socks/stockings because of the pain in my back.

I only walk short distances because of my back pain.

I sleep less well because of my back pain.

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

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

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

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

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

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

Rate the severity of your pain:
0 (no pain) - 10 (unbearable pain) 

Full Name:
 
Street:
 
City:
 
State:
 
Zip Code:
 
Phone Number (home):
 
Phone Number (work):
 
Best Time to Call:
 
Email Address:
 

Physician's Name (please include first initial or name):
 
Physician's Street:
 
Physician's City:
 
Physician's Phone Number:
 
Describe Your Back Problem:

Your personal information will never be shared or sold.
It will only be used to contact you regarding treatment.