Self-assessment surveys - Pages

1 / 12

If you're not sure how to answer a question, please, choose the closest option given.

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Please, answer all questions regarding the current condition of your lower back for the past month.

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3 / 12

How serious is the pain you feel in your lower back?

Please choose one of the options

I don't feel pain at all.

I feel mild pain.

I feel moderate pain.

I feel severe pain.

I feel excrutiating pain.

I feel the worst possible pain ever.

4 / 12

Can you take care for yourself?

Please choose one of the options

I have no problems with taking care for myself.

I can take care for myself, but I feel pain.

I can take care for myself, but I feel severe pain.

I can use some help, because the pain is too much.

I have hard times putting my clothes on, I can't take a bath and I prefer staying in my bed.

5 / 12

How affected is your ability to lift up objects?

Please choose one of the options

I can do that. I feel no pain.

I can do that, but I feel pain.

I can do that, but only if the objects are placed high like on a desk or table.

I can do that, but only if the objects are light weight and placed high like on a desk or a table.

I can lift only light weight objects.

I cannot lift up anything.

6 / 12

How affected is your ability to walk?

Please choose one of the options

The pain does not interfere with my walking.

I can walk, but no more than 1 kilometer because of the pain.

I can walk, but no more than 500 meters because of the pain.

I can walk, but no more than 100 meters because of the pain.

I can walk only if I have a cane or a crutch.

I stay in my bed and I do not walk.

7 / 12

How affected is the sitting position?

Please choose one of the options

I can be seated on a chair, no problem.

I can sit for a long period of time only if the chair is comfortable enough.

I cannot be seated for more than an hour.

I cannot be seated for more than half an hour.

I cannot be seated for more than 10 minutes.

I cannot sit.

8 / 12

How affected is the upright position?

Please choose one of the options

I can be standing up with for a long period of time.

I can be standing up for a long time, but that would initiate pain.

I can be standing up for not more than an hour.

I can be standing up for not more than half an hour.

I can be standing up for not more than 10 minutes.

I cannot stand up.

9 / 12

How does your lower back pain affect your sleep?

Please choose one of the options

It doesn't interfere with my sleep.

Sometimes it wakes me up at night.

I cannot sleep more than 6 hours because of the pain.

I cannot sleep more than 4 hours because of the pain.

I cannot sleep more than 2 hours because of the pain.

I cannot sleep at all.

10 / 12

How affected is your sexual life ( if you are a sexually active individual)?

Please choose one of the options

I can have a sexual intercourse with no pain.

I can feel some pain while having sex.

I can feel moderate pain while having sex.

Pain is preventing me from having a good sexual intercourse.

I rarely have sex because of the pain.

I do not have sex because of the pain.

11 / 12

How affected is your social life?

Please choose one of the options

My social life is not affected at all.

My social life is not affected at all, despite the pain.

My social life is ok, but I cannot do sports or dancing.

My social life is limited because of the pain.

My social life has shrinked within my family because of the pain.

I do not have a social life.

12 / 12

How your lower back condition would affect a trip.

Please choose one of the options

I can have a trip, no problem.

I can have a trip with a minor pain.

My pain is strong, but still I can have a trip.

My pain doesn't allow me to have a trip more than an hour long.

My pain doesn't allow me to have a trip more than half an hour long.

I can go for a trip only if it is for a treatment.