Low Back Pain & Disability Questionnaire

Name *

First Name

Last Name

Date

MM

DD

YYYY

When your back hurts, you may find it difficult to do some of the things you normally do. Mark only the sentences that describe you today.

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

I walk more slowly than usual because of my back

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

Because of my back, I use a handrail to get up stairs

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

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

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

Because of my back, I get dressed more slowly than usual

Because of my back, I stand up only for short periods of time

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

Because of my back, I find it difficult to get out of my chair

My back or leg is painful almost all of the time

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

Because of my back, I have trouble putting on socks.

Because of my back, I don't sleep well

Because of my back, I avoid heavy jobs around the house.

Because of my back, i am more irritable and bad tempered than usual.

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