Personal DetailsName * Email * Back PainPlease describe where your pain is : Is the pain worse on one side of the spine ? *LeftRightBoth sides Does your back feel stiff in the mornings but gets better after a while ? NoYes Is the pain worse at the end of the day or when you sit for long periods ? NoYes Is pain is worse after impact sports such as tennis or football ? YesNo Does pain refer into one or both legs below the thighs NoOne leg onyYes both legs Is your Walking restricted ? nocan only walk half a milecan only walk 100 yrdsCannot walk Is there weakness in one or both legs Weakness in one legWeakness in both legsNo weakness in legs Is there numbness in one or both legs No Numbness in legsOne egBoth legs How long have you had these symptoms *Less than 2 weeks2 - 6 weeks6 weeks to 6 monthsLonger than 6 months Is pain better when you lie down ? YesNo Do you have any problems in controlling bowels or urine ? *No - Bowels and Bladder are working fineYes - Loss of functional control Functional Assessment ScoreOswestry Disability Questionnaire This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realise you may consider that two or more statements in any one section apply, but please just select one that indicates the statement which most clearly describes your problem. Section 1: Pain Intensity *I have no pain at the momentThe pain is very mild at the momentThe pain is moderate at the momentThe pain is fairly severe at the momentThe pain is very severe at the momentThe pain is the worst imaginable at the moment Section 2: Personal Care (eg. washing, dressing) I can look after myself normally without causing extra painI can look after myself normally but it causes extra painIt is painful to look after myself and I am slow and carefulI need some help but can manage most of my personal careI need help every day in most aspects of self-careI do not get dressed, wash with difficulty and stay in bed Section 3: Lifting I can lift heavy weights without extra painI can lift heavy weights but it gives me extra painPain prevents me lifting heavy weights off the floor but I can manage if they are conveniently placed (eg. on a table)Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positionedI can only lift very light weightsI cannot lift or carry anything Section 4: Walking* Pain does not prevent me walking any distancePain prevents me from walking more than 1 milePain prevents me from walking more than ½ milePain prevents me from walking more than 100 yardsI can only walk using a stick or crutchesI am in bed most of the time Section 5: Sitting I can sit in any chair as long as I likeI can only sit in my favorite chair as long as I likePain prevents me sitting more than one hourPain prevents me from sitting more than 30 minutesPain prevents me from sitting more than 10 minutesPain prevents me from sitting at all Section 6: Standing I can stand as long as I want without extra painI can stand as long as I want but it gives me extra painPain prevents me from standing for more than 1 hourPain prevents me from standing for more than 30 minutesPain prevents me from standing for more than 10 minutesPain prevents me from standing at all Section 7: Sleeping My sleep is never disturbed by painMy sleep is occasionally disturbed by painBecause of pain I have less than 6 hours sleepBecause of pain I have less than 4 hours sleepBecause of pain I have less than 2 hours sleepPain prevents me from sleeping at all Section 8: Sex Life (if applicable) My sex life is normal and causes no extra painMy sex life is normal but causes some extra painMy sex life is nearly normal but is very painfulMy sex life is severely restricted by painMy sex life is nearly absent because of painPain prevents any sex life at all Section 9: Social Life My social life is normal and gives me no extra painMy social life is normal but increases the degree of painPain has no significant effect on my social life apart from limiting my more energetic interests e.g. sportPain has restricted my social life and I do not go out as oftenPain has restricted my social life to my homeI have no social life because of pain Section 10: Traveling I can travel anywhere without painI can travel anywhere but it gives me extra painPain is bad but I manage journeys over two hoursPain restricts me to journeys of less than one hourPain restricts me to short necessary journeys under 30 minutesPain prevents me from travelling except to receive treatment Roland Morris Disability ScoreDisability Questionnaire When your back hurts, you may find it difficult to do some of the things you normally do. This list contains 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 you today, put a tick against it. If the sentence does not describe you, then leave the space blank and go on to the next one. Remember, only tick the sentence if you are sure it describes you today.1. I stay at home most of the time because of my back.2. I change position frequently to try and get my back comfortable.3. I walk more slowly than usual because of my back.4. Because of my back I am not doing any of the jobs that I usually do around the house.5. Because of my back, I use a handrail to get upstairs.6. Because of my back, I lie down to rest more often.7. Because of my back, I have to hold on to something to get out of an easy chair.8. Because of my back, I try to get other people to do things for me.9. I get dressed more slowly then usual because of my back.10. I only stand for short periods of time because of my back.11. Because of my back, I try not to bend or kneel down.12. I find it difficult to get out of a chair because of my back.13. My back is painful almost all the time.14. I find it difficult to turn over in bed because of my back.15. My appetite is not very good because of my back pain.16. I have trouble putting on my socks (or stockings) because of the pain in my back.17. I only walk short distances because of my back.18. I sleep less well because of my back.19. Because of my back pain, I get dressed with help from someone else.20. I sit down for most of the day because of my back.21. I avoid heavy jobs around the house because of my back.22. Because of my back pain, I am more irritable and bad tempered with people than usual.23. Because of my back, I go upstairs more slowly than usual.24. I stay in bed most of the time because of my back. Visual Analogue ScoresPain Intensity - Please estimate how intense your pain is now 0. No Pain1345678910. Worst possible pain Coping-Please estimate how confident you feel at coping witha flare up 0. Totally Confident12345678910. No Confidence Average pain intensity - please estimate your average pain over the last week 0. No Pain12345678910. Worst possible pain Distress-Estimate how distressing your problem has been over last week: 0. No Distress12345678910. Totally distressing VerificationPlease enter your age with no spaces (Example: 32) *This box is for spam protection - please leave it blank Like
