Low Back Pain Questionnaire
Please answer all questions honestly. Your responses help us understand your condition and determine the best path forward.
Patient Information
Full name*
Date of birth*
Screening
Is your low back pain currently your biggest concern and your main reason for seeking treatment?*
Thank you for your time. This questionnaire is specifically for patients whose primary concern is low back pain. Please speak with your provider about your other concerns, or call our office for assistance.
Pain Profile
Does your low back pain radiate into your leg?*
Is your pain more noticeable in your back or in your leg?*
How long has your low back pain affected your day-to-day life in a significant way?*
On a scale of 1–10, how bad is your back pain on a bad day?*
Very mildVery extreme
Treatment History
Have you tried any of the following treatments? (Select all that apply)*
Have you previously had surgery on your low back involving instruments like rods or screws, or an implant?*
Please select all statements below that are TRUE for you:
Functional Assessment
Please answer the following questions about your low back pain:*
Question
Yes, often
Sometimes
No, never
Does your back ever feel like it is unstable?
Do you get surprised by sudden pain or spasms when you do mild back movements or light tasks?
Do you struggle with activities such as brushing teeth over the sink, washing dishes, or unloading the dishwasher?
Does your back feel tired or painful the longer you maintain a position (standing, sitting, etc.)?
Do you tend to support yourself with your arms while standing, sitting, or performing light tasks?
Do you experience stiffness in your low back in the morning or after periods of inactivity?
Do backrests and back braces help when sitting or standing for long periods?
What does your back pain keep you from doing? (Select all that apply)
Motivation & Employment
Are you currently employed?*
Are you retired?*
Have you ever missed work due to your back pain?*
In a 30-day period, how many days have you missed?*
Would you consider a minimally invasive implant if it could help restore function and decrease pain in your low back?*
How interested are you in learning about a new implantable treatment for your low back pain?*
Insurance
What health insurance do you have? (Select all that apply)*