Back Pain Questionnaire Pdf

Thinking about the last 2 weeks tick your response to the following questions. Low back disability questionnaire revised oswestry estionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in ay life.

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Back pain questionnaire page 2 of 3 patient name.

Back pain questionnaire pdf. Add up the. Fritz jm irrgang jj. Remember this questionnaire is not asking whether of not you have been doing these things but rather how confident you are that you can do them at present despite the pain.

When your back hurts you may find it difficult to do some of the things you normally do. The roland morris low back pain and disability questionnaire patient name. A comparison of a modified oswestry low back pain disability questionnaire and the quebec back pain disability scale.

Amodified by fritz irrgang with permission of the chartered society of physiotherapy from fairbanks jct couper j davies jb et al. People with back problems may find it difficult to perform some of their daily activities. For each question there is a possible 5 points.

Policy number 3 authorization signature of person to be insured date dd mmm yyyy signature of witness date dd. This questionnaire is about the way your back pain is affecting your daily life. Back pain questionnaire for disability insurance use this form to detail back pain problems please print clearly.

The quebec back pain disability scale. 0 for the first answer 1 for the second answer etc. Please answer each section and mark in each section only one box.

The oswestry low back pain questionnaire physiotherapy 1980. Please answer by checking one box in each section for the statement which best. The keele start back screening tool patient name.

This questionnaire has been designed to give the doctor information about how your neck pain has affected your ability to manage in everyday life. We would like to know if. This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life.

Disagree agree 0 1 1 my back 2 i have had pain in the shoulder or neck.

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