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.
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General Internet communication is inherently not secure. For this reason, we highly recommend that data considered confidential or private in nature not be submitted on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.)