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Low Back Pain Quiz

* Name:
* Email:
Phone:
* I stay at home most of the time because of my back.
Yes
No
* I change position frequently to try and get my back comfortable.
Yes
No
* I walk more slowly than usual because of my back.
Yes
No
* Because of my back I am not doing any of the jobs that I usually do around the house.
Yes
No
* Because of my back, I use a handrail to get upstairs.
Yes
No
* Because of my back, I lie down to rest more often.
Yes
No
* I get dressed more slowly then usual because of my back.
Yes
No
* I only stand for short periods of time because of my back.
Yes
No
* I find it difficult to get out of a chair because of my back.
Yes
No
* My back is painful almost all the time.
Yes
No
* I find it difficult to turn over in bed because of my back.
Yes
No
* I only walk short distances because of my back.
Yes
No
* I sleep less well and/or lose sleep because of my back.
Yes
No
* Because of my back pain, I am more irritable and bad tempered with people than usual.
Yes
No
* I stay in bed most of the time because of my back
Yes
No
* Pain Intensity
* Sleeping Habits

*required information