Tell Us About Your Back Pain Survey

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* 3. What is your age?

18 - 25

26 - 35

36 - 45

46 - 55

56 - 65

66 - 75

76 - 85

85 +

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* 4. To date how long have you had this episode of back pain?

0 - 1 Week

1 - 2 Weeks

2 - 4 Weeks

4 - 6 Weeks

6 - 12 Weeks

3 - 6 Months

6- 12 Months

1 - 2 Years

2 - 5 Years

5 + Years

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* 5. How often do you get back pain?

This is my first ever episode

Multiple episodes 5 or below

Multiple episodes above 5

How long ago was your first episode?

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* 6. Where is your pain? (Tick multiple boxes if it applies)

Lumbar region

Top of the buttock

Buttock

Down the back of the leg

Down the front of the leg

Groin

Side of the hip

Other (please specify)

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* 7. Describe your pain? (Tick multiple boxes if it applies)

Pain

Ache

Soreness

Pins and needles

Numbess

Burning

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* 8. What is your frequency of pain?

Pain occaisonally in the week, eases at rest

Pain occaisionally in the day, eases at rest

Pain many times a day, eases at rest

Pain evertime you move, eases at rest

Constant pain which occaisionally gets worse on movement

Constant pain which increases everytime you move

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* 9. On a scale of 0 - 10 over the last few days, when your pain is at its WORSE what level is it?

10 Excruciating pain

8 Very bad pain

6 Bad pain

4 Moderate pain

2 Mild pain

0 No pain

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* 10. What is your "Fear level" regarding your back pain?

10 Extremley Fearful

0 No Fear

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* 11. What is your "Stress level" regarding your back pain?

10 Extremely stressed

0 No Stress

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* 12. Can you rate how much your back pain effects your sleep?

10 I get no sleep because of my back pain

0 My back has no effect on my sleeping

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* 13. Please list in order the activities that you spend the most time doing in the week/month?
e.g. 1. Sat a desk working 2.Gardening 3.Riding my bike

Activity you spend most doing?

Activity you spend 2nd most time doing?

Activity you spend 3rd most time doing?

Yes

I stay at home most of the time because of my back.

I stay at home most of the time because of my back. Yes

I stay at home most of the time because of my back. NO

I change position frequently to try and get my back comfortable.

I change position frequently to try and get my back comfortable. Yes

I change position frequently to try and get my back comfortable. NO

I walk more slowly than usual because of my back.

I walk more slowly than usual because of my back. Yes

I walk more slowly than usual because of my back. NO

Because of my back I am not doing any of the jobs that I usually do around the house.

Because of my back I am not doing any of the jobs that I usually do around the house. Yes

Because of my back I am not doing any of the jobs that I usually do around the house. NO

Because of my back, I use a handrail to get upstairs.

Because of my back, I use a handrail to get upstairs. Yes

Because of my back, I use a handrail to get upstairs. NO

Because of my back, I lie down to rest more often

Because of my back, I lie down to rest more often Yes

Because of my back, I lie down to rest more often NO

Because of my back, I have to hold on to something to get out of an easy chair.

Because of my back, I have to hold on to something to get out of an easy chair. Yes

Because of my back, I have to hold on to something to get out of an easy chair. NO

Because of my back, I try to get other people to do things for me.

Because of my back, I try to get other people to do things for me. Yes

Because of my back, I try to get other people to do things for me. NO

I get dressed more slowly than usual because of my back

I get dressed more slowly than usual because of my back Yes

I get dressed more slowly than usual because of my back NO

I only stand for short periods of time because of my back.

I only stand for short periods of time because of my back. Yes

I only stand for short periods of time because of my back. NO

Because of my back, I try not to bend or kneel down

Because of my back, I try not to bend or kneel down Yes

Because of my back, I try not to bend or kneel down NO

I ﬁnd it difﬁcult to get out of a chair because of my back

I ﬁnd it difﬁcult to get out of a chair because of my back Yes

I ﬁnd it difﬁcult to get out of a chair because of my back NO

My back is painful almost all the time

My back is painful almost all the time Yes

My back is painful almost all the time NO

I ﬁnd it difﬁcult to turn over in bed because of my back

I ﬁnd it difﬁcult to turn over in bed because of my back Yes

I ﬁnd it difﬁcult to turn over in bed because of my back NO

My appetite is not very good because of my back pain

My appetite is not very good because of my back pain Yes

My appetite is not very good because of my back pain NO

I have trouble putting on my socks (or stockings) because of the pain in my back

I have trouble putting on my socks (or stockings) because of the pain in my back Yes

I have trouble putting on my socks (or stockings) because of the pain in my back NO

I only walk short distances because of my back

I only walk short distances because of my back Yes

I only walk short distances because of my back NO

I sleep less well on my back

I sleep less well on my back Yes

I sleep less well on my back NO

Because of my back pain, I get dressed with help from someone else.

Because of my back pain, I get dressed with help from someone else. Yes

Because of my back pain, I get dressed with help from someone else. NO

I sit down for most of the day because of my back

I sit down for most of the day because of my back Yes

I sit down for most of the day because of my back NO

I avoid heavy jobs around the house because of my back.

I avoid heavy jobs around the house because of my back. Yes

I avoid heavy jobs around the house because of my back. NO

Because of my back pain, I am more irritable and bad tempered with people than usual

Because of my back pain, I am more irritable and bad tempered with people than usual Yes

Because of my back pain, I am more irritable and bad tempered with people than usual NO

Because of my back, I go upstairs more slowly than usual.

Because of my back, I go upstairs more slowly than usual. Yes

Because of my back, I go upstairs more slowly than usual. NO

I stay in bed most of the time because of my back

I stay in bed most of the time because of my back Yes

I stay in bed most of the time because of my back NO

Tell Us About Your Back Pain

The information given will be anonymously used to create statistics to ensure efficacy and safety

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* 1. Patient details

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* 2. What is your gender?

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* 3. What is your age?

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* 4. To date how long have you had this episode of back pain?

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* 5. How often do you get back pain?

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* 6. Where is your pain? (Tick multiple boxes if it applies)

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* 7. Describe your pain? (Tick multiple boxes if it applies)

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* 8. What is your frequency of pain?

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* 9. On a scale of 0 - 10 over the last few days, when your pain is at its WORSE what level is it?

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* 10. What is your "Fear level" regarding your back pain?

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* 11. What is your "Stress level" regarding your back pain?

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* 12. Can you rate how much your back pain effects your sleep?

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* 13. Please list in order the activities that you spend the most time doing in the week/month?
e.g. 1. Sat a desk working 2.Gardening 3.Riding my bike

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* 14. Can you rate how much your back pain stops you from doing the activities you enjoy doing?

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* 15. Can you answer yes or no to the following questions regarding you back and/or leg pain. (Note back and leg pain are interchangeable)

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* 1. Patient details

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* 2. What is your gender?

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* 3. What is your age?

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* 4. To date how long have you had this episode of back pain?

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* 5. How often do you get back pain?

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* 6. Where is your pain? (Tick multiple boxes if it applies)

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* 7. Describe your pain? (Tick multiple boxes if it applies)

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* 8. What is your frequency of pain?

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* 9. On a scale of 0 - 10 over the last few days, when your pain is at its WORSE what level is it?

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* 10. What is your "Fear level" regarding your back pain?

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* 11. What is your "Stress level" regarding your back pain?

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* 12. Can you rate how much your back pain effects your sleep?

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* 13. Please list in order the activities that you spend the most time doing in the week/month? e.g. 1. Sat a desk working 2.Gardening 3.Riding my bike

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* 14. Can you rate how much your back pain stops you from doing the activities you enjoy doing?

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* 15. Can you answer yes or no to the following questions regarding you back and/or leg pain. (Note back and leg pain are interchangeable)

* 13. Please list in order the activities that you spend the most time doing in the week/month?
e.g. 1. Sat a desk working 2.Gardening 3.Riding my bike