LOW BACK PAIN QUESTIONNAIRE

Name- _____________ Date- _______________

Age- _______________ Gender- ________________
Occupation- ____________ Marital status- ______________
Section –A
Pain features
1. Mark the location of back pain on the body diagram.

2. From how long do you have this back pain.

a) Less than 7 days b) 7 days – 7 weeks c) more than 7 weeks

3. Do you know what started the pain you are suffering? If yes, describe what started your pain.

___________________________________________________________

4. How severe is your back pain, mark on the scale.

5. Does the pain goes to the leg or foot? Yes No

If yes, where do you feel pain? _________________

6. Have you noticed any weakness? Yes No

If yes, where do you feel weak? ________________

7. Have you ever had surgery on your back? Yes No

If yes, please indicate what was done ________________