Please complete this form prior to your consultation.

The information will help us in determining a diagnosis and treatment.

Please note that all information is kept strictly confidential and will not be disclosed to any third parties.

Personal Details

 

Regarding you Back pain ;

 

Functional Assessment Score

  • 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.
 

Roland Morris Disability Score

 

Visual Analogue Scores

 

Verification