Patient Name:  Date:

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SECTION 1 - PAIN INTENSITY
0 The pain comes and goes and is very mild.
1 The pain is mild and does not vary much.
2 The pain comes and goes and is moderate.
3 The pain is moderate and does not vary much.
4 The pain comes and goes and is severe.
5 The pain is severe and does not vary much.

SECTION 2 - PERSONAL CARE
0 I do not have to change my way of washing or dressing to accommodate my pain.
1 I do not normally change my way of washing or dressing even though it causes some pain.
2 Washing and dressing increase the pain, but I manage not to change my way of doing it.
3 Washing and dressing increases the pain, and I find it necessary to change my way of doing it.
4 Because of the pain, I am unable to do some washing and dressing without help.
5 Because of the pain, I am unable to do any washing and dressing without help.

SECTION 3 - LIFTING
0 I can lift heavy weights without extra pain.
1 I can lift heavy weights, but it causes extra pain.
2 Pain prevents me from lifting heavy weights off the floor.
3 Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g. on a table.
4 Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.
5 I can only lift very light weights, at the most.

SECTION 4 - WALKING
0 Pain does not prevent me from walking any distance.
1 Pain prevents me from walking more than one mile.
2 Pain prevents me from walking more than 1/2 mile.
3 Pain prevents me from walking more than 1/4 mile.
4 I can only walk using an aid, e.g. cane, crutches, or walker.
5 I am in bed most of the time and have to crawl to the toilet.

SECTION 5 - SITTING
0 I can sit in any chair as long as I like without pain.
1 I can only sit in my favorite chair as long as I like.
2 Pain prevents me from sitting more than one hour.
3 Pain prevents me from sitting more than 1/2 hour.
4 Pain prevents me from sitting more than 10 minutes.
5 Pain prevents me from sitting at all.

SECTION 6 - STANDING
0 I can stand as long as I want without pain.
1 I have some pain while standing, but it does not increase with time.
2 I cannot stand for longer than one hour without increasing pain.
3 I cannot stand for longer than 1/2 hour without increasing pain.
4 I cannot stand for longer than 10 minutes without increasing pain.
5 I avoid standing, because it increases the pain right away.

SECTION 7 - SLEEPING
0 I get no pain in bed.
1 I get no pain in bed, but it does prevent me from sleeping well.
2 Because of the pain, my normal night's sleep is reduced by 25%.
3 Because of the pain, my normal night's sleep is reduced by one-half.
4 Because of the pain, my normal night's sleep is reduced by 75%.
5 Pain prevents me from sleeping at all.

SECTION 8 - SOCIAL LIFE
0 My social life is normal and causes no pain.
1 My social life is normal, but increases the degree of my pain.
2 Pain has no significant effect on my social life apart from limiting my most energetic interests, e.g. dancing, etc.
3 Pain has restricted my social life and I do not go out very often.
4 Pain has restricted my social life to my home.
5 I have hardly any social life because of the pain.

SECTION 9 - TRAVELING
0 I get no pain while traveling.
1 I get some pain while traveling, but none of my usual forms of travel makes it any worse.
2 I get extra pain while traveling, which it does not compel me to seek alternative forms of travel.
3 I get extra pain while traveling, which compels me to seek alternative forms of travel.
4 Pain restricts all forms of travel.
5 Pain prevents all forms of travel except that done lying down.

SECTION 10 - CHANGING DEGREE OF PAIN
0 My pain is rapidly getting better.
1 My pain fluctuates, but overall, is definitely getting better.
2 My pain seems to be getting better, but improvement is slow at present.
3 My pain is neither getting better or worse.
4 My pain is gradually worsening.
5 My pain is rapidly worsening.

Once your Low Back Pain Questionnaire is scored and reviewed by one of our physicians (approximately 3 to 4 days), you will be contacted by telephone to arrange for a consultation. This consultation can be performed with you:

  Over the telephone

  By an appointment in one of our offices.

There is no charge for either type of consultation!

(sends the completed form)           (clears your answers)

Press the SUBMIT button to send your completed Low Back Pain Questionnaire directly to Physicians First, Inc.