Client Intake - RMPQ

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.

Question Title

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

Question Title

* 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.

I stay at home most of the day because of my back pain.

I change my position frequently to allow my back to be more comfortable.

I walk slower than usual because of my back pain.

Because of my back pain, I am not doing any of the jobs that I usually do around the house.

Because of my back pain, I use a handrail to get upstairs

Because of my back pain, I lie down to rest more often than usual.

Because of my back pain, I have to hold on to something to get out of an armchair.

Because of my back pain, I ask other people to do things for me.

I get dressed slower than usual because of my back pain.

I stand up only for short periods of time because of my back pain.

Because of my back pain, I try not to bend over or kneel down.

I find it difficult to get out of a straight-backed chair because of my back pain.

My back is painful most of the day.

I find it difficult to turn over in bed because of my back pain.

Because of my back pain, my appetite is not very good.

I have trouble putting on my socks (or stockings) because of my back pain.

Because of my back pain, I walk only short distances.

I sleep less than usual because of my back pain.

Because of my back pain, I get dressed with help from someone else.

I spend most of the day sitting because of my back pain.

I avoid heavy jobs around the house because of my back pain.

Because of my back pain, I am more irritable and bad tempered than usual with people.

Because of my back pain, I go upstairs slower than usual.

I stay in bed most of the day because of my back pain.

Question Title

* 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

Question Title

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

Question Title

Question Title

* 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)

* 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)