This questionnaire is designed to give us information as to how your back (or leg) trouble affects your ability to manage in everyday life.

Please answer every section. Mark one box only in each section that most closely describes you today.


Required fields are marked with an asterisk *.
Pain Intensity
Personal Care (Washing, Dressing etc.)
Lifting
Walking
Sitting
Standing
Sleeping
Sex Life (if applicable)
Social Life
Traveling
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