Back Pain Questionnaire

Welcome to Resolution Physiotherapy & IMS Clinic and thank you for choosing our team of Physiotherapists to help resolve your pain. We look forward to meeting you and showing you how effective our team of highly qualified Physiotherapists can be.

Please complete this questionnaire if our Physiotherapists are treating you for back pain.  

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* 1. Please type your name. Surname, First Name

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* 2. When your back hurts, you may find it difficult to do some of the things you normally do.

This list contains sentences that people have used to describe themselves when they have back pain. When you read them, you may find that some stand out because they describe you today.

As you read the list, think of yourself today. When you read a sentence that describes you today, put a tick against it. If the sentence does not describe you, then leave the space blank and go on to the next one. 

Remember, check mark the sentence only if you are sure that it describes you today.

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* 3. Interpretation of scores (for office use only)

Total score = # of checked boxes = _________
         MCID = 3.5 points. SCORE RANGE 0 (no disability) to 24 (max disability)

This questionnaire is taken from: Roland MO, Morris RW. A study of the natural history of back pain. Part 1: Development of a reliable and sensitive measure of disability in low back pain. Spine 1983; 8: 141-144