Back Questionnaire Back Questionnaire In order to better help you with your back, please answer the following questions: Name Name First First Last Last How long have you had back pain if at all? Known Diagnosis related to your back, if any (e.g. bulging disk, degeneration, fusion, arthritis, herniated disk, etc.) Other known diagnosis (e.g. neck out of alignment, frozen shoulder, scoliosis, etc.) Indicate what part of your back is problematic, if known. Include which vertebrae, if known (e.g. cervical, thoracic, lumbar, sacral, C-6, L-5/S-1, L-4/L-5, etc.) Where do you have pain today if at all? Please indicate from 1 (lowest) to 5 (highest) the degree upper back 1 2 3 4 5 low back 1 2 3 4 5 neck 1 2 3 4 5 shoulder 1 2 3 4 5 hip 1 2 3 4 5 knee 1 2 3 4 5 mid back 1 2 3 4 5 feet 1 2 3 4 5 down my leg 1 2 3 4 5 Others (pls specify) Have you had surgery related to your back? Yes No If so, when and what? What if anything has been helpful for your back pain? stretching yoga exercise walking abdominal strengthening other strengthening pain medication anti-inflammatories muscle relexants pain medication, prescription getting into certain positions avoiding certain positions Pain medication, over the counter, please specify Anti-inflammatories, please specify Muscle relaxants, please specify Pain medication, prescription, please specify Getting into certain positions, please specify Avoiding certain positions, please specify What moves if any make the pain worse? Any other info? Please use the other side if needed. Submit If you are human, leave this field blank. Δ
