Use the mouse and click on the option that represents closest to how you feel today
You have not indicated your choice here The pain comes and goes and is very mild The pain is mild and does not vary much The pain comes and goes and is moderate The pain is moderate and does not vary much The pain comes and goes and is severe The pain is severe and does not vary much
You have not indicated your choice here 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
You have not indicated your choice here I can lift heavy objects without extra pain I can lift heavy objects but it gives extra pain I can't lift heavy objects from off the floor but off a table is OK I can't lift heavy objects but light to medium ones are OK I can only lift very light weights I cannot lift of carry anything at all
You have not indicated your choice here Pain does not prevent me from walking any distance Pain prevents me from walking more than about two kilometers Pain prevents me from walking more than one kilometer Pain prevents me from walking more than half a kilometer I can only walk using a stick or crutches I am in bed most of the time and have to crawl to the toilet
You have not indicated your choice here I can sit in any chair as long as I like I can sit in my favourite 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 at all
You have not indicated your choice here I can stand as long as I want without extra pain I can stand as long as I want but it gives extra pain Pain prevents me from standing for more than 1 hour Pain prevents me from standing for more than 30 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all
You have not indicated your choice here yet 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 six hours of sleep Even when I take tablets I have less than four hours of sleep Even when I take tablets I have less than two hours of sleep Pain prevents me from sleeping at all
You have not indicated your choice here My social life is normal and gives me no extra pain My social life is normal but increases the degree of pain I can't participate in more energetic activities like tennis Pain restricts my social life and I don't go out as often Pain restricts my social life to my home I have no social life because of pain
You have not indicated your choice here I can travel anywhere without pain I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys over two hours Pain restricts me to journeys of less than one hour Pain restricts me to short necessary journeys of less than 30 minutes Pain prevents me from traveling (except to my health practitioner)
You have not indicated your choice here 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 present My pain is neither getting better nor worse My pain is gradually worsening My pain is rapidly worsening
You can review your responses by clicking the forward and back links. Your selections remain until you click the < Submit > button below. Date: Date of low back problem beginning (approx if not sure): First name: Last name: Male Female
