LBP Assessment - Physio Ed.

Step 1 of 12

Pain Intensity(Required)

I have no pain at the moment.

The pain is very mild at the moment. (1-3)

The pain is moderate at the moment. (3-6)

The pain is fairly severe at the moment. (6-8)

The pain is extreme at the moment. (8-10)

Pain Tracking(Required)

My pain is rapidly getting better.

My pain fluctuates, but overall is getting better.

My pain is neither getting better or worse.

My pain is gradually worsening.

My pain is rapidly worsening.

Personal Care(Required)

I do not have to change my way of washing or dressing to avoid pain.

Washing or dressing increases the pain but I manage not to change the way I’m doing it.

Washing and dressing increases the pain and I need to find ways to do them differently.

Because of the pain I am unable to do some washing and dressing activities without help.

I can’t dress myself and need help with washing.

Lifting(Required)

I can lift heavy things without extra pain.

I can lift heavy things, but it hurts more.

I can’t lift heavy things off the floor, but I can if they’re on a table.

I can only lift light to medium things.

I can’t lift or carry anything.

Walking(Required)

Pain doesn’t stop me from walking any distance.

Pain stops me from walking more than a mile.

Pain stops me from walking more than half a mile.

Pain stops me from walking more than a quarter mile.

I need a stick or crutches to walk.

Sitting(Required)

I can sit in any chair for as long as I like.

I can only sit in my favorite chair for as long as I like.

Pain stops me from sitting more than an hour.

Pain stops me from sitting more than half an hour.

Pain stops me from sitting at all.

Standing(Required)

I can stand as long as I want without extra pain.

I can stand as long as I want, but it hurts more.

Pain stops me from standing more than an hour.

Pain stops me from standing more than half an hour.

Pain stops me from standing at all.

Sleeping(Required)

Pain doesn’t stop me from sleeping well.

Pain reduces my normal sleep by 1/4 each night.

Pain reduces my sleep by 1/2 each night.

Pain reduces my sleeping by 3/4 each night.

Pain stops me from sleeping at all.

Traveling(Required)

I can travel anywhere without extra pain.

I can travel anywhere, but it causes extra pain.

Pain is bad, but I manage long journeys.

Pain restricts me to short journeys.

Pain stops me from traveling except for treatment.

Work and Home(Required)

My job/homemaking activities don’t cause pain.

My job/homemaking activities cause pain, but I can still do them.

I can do most of my duties, but pain stops me from doing more physical tasks.

Pain stops me from doing anything but light duties.

Pain stops me from doing any job or homemaking chores.

Do you have incontinence or feel numbness in the groin area?(Required)

Yes

Do you currently have pain associated with significant weakness in your leg?(Required)

Yes

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Total Score

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