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717-944-2225

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Agenda tu cita

Ask Us A Question

Schedule Appointment

Back Index

Low Back Pain Questionnaire

Please Read: This questionnaire is designed to enable us to understand how much your low back pain has affected your ability to manage your everyday activities. Please answer each section by choosing the one choice that most applies to you.

Name(Required)
MM slash DD slash YYYY
SECTION 1 — Pain Intensity(Required)
SECTION 2 — Personal Care(Required)
SECTION 3 — Lifting(Required)
SECTION 4 — Walking(Required)
SECTION 5 — Sitting(Required)
SECTION 6 — Standing(Required)
SECTION 7 — Sleeping(Required)
SECTION 8 — Social Life(Required)
SECTION 9 — Traveling(Required)
SECTION 10 — Changing Degree of Pain(Required)