DIRECTIONS: CIRCLE THE POSITION THAT

FEELS BETTER AND CIRCLE THE NUMBER

FOR THE PAIN OF EACH ACTIVITY

Circle Posi+on Feels Be/er On Stomach On Back Feet UP

This is for BACK PAIN only not for Neck Pain! 1-10 pain scale 1 is Good and 10 is Bad.

1. BENDING FORWARD BENDING BACKWARD

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
2. SLEEPING ON BACK WITH KNEES BENT/PILLOW UNDER SLEEPING ON STOMACH
THE KNEES\
0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
3. LYING DOWN IN FETAL POSITION OR LYING ON BACK LYING DOWN ON STOMACH, PROPPED UP ON
ELBOWS
0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
4. SITTING SLOUCHED SITTING UP TALL

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
5. TRANSITIONING FROM SITTING TO STANDING TRANSITIONING FROM STANDING TO SITTING

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
6. SQUATTING/CROUCHING STANDING

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
7. SITTING WALKING

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
8. WALKING UPHILL, ON AN INCLINE WALKING DOWNHILL, ON A DECLINE

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
9. GOING UP STAIRS GOING DOWN STAIRS

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
10. LEANING FORWARD ON GROCERY CART FOR SUPPORT STANDING STRAIGHT UP TO PUSH GROCERY CART
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
11. LEANING FORWARD/SLOUCHNG IN THE CHAIR BENDING BACK WHILE SITTING IN THE CHAIR

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
12. BRUSHING TEETH GARGLING MOUTHWASH

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
13. WORK REQUIRING CROUCHING (WORKING IN A OVERHEAD WORK (CHANGING A LIGHTBULB,
CRAWLSPACE, ROOFING, ETC) PAINTING, WORKING ON LADDER)

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10

Total Column 1: _____ Total Column 2:_______

Column 1 > Column 2 = Extension bias Column 2 > Column 1 = Flexion bias