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

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

I walk more slowly than usual because of my back.

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

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

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

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

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

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

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

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

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

My back is painful almost all the time.

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

My appetite is not very good because of my back.

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

I only walk short distances because of my back pain.

I sleep less well because of my back pain.

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

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

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

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

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

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

Rate the severity of your pain: 0 1 2 3 4 5 6 7 8 9 10
0 (no pain) - 10 (unbearable pain) 

Full Name:
 
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Physician's Name (please include first initial or name):
 
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Describe Your Back Problem: