Patient Questionnaire

None

Mild

Moderate

Moderate to severe

Severe

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Which one of the following best describes the amount of pain you have experienced over the last month?

None

Mild

Moderate

Moderate to severe

Severe

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During the past 6 months have you been a very nervous person?

None of the time

A little of the time

Some of the time

Most of the time

All of the time

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If you had to spend the rest of your life with your back shape as it is right now, how would you feel about it?

Very happy

Somewhat happy

Neither happy nor unhappy

Somewhat unhappy

Very unhappy

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What is your current level of activity?

Bedridden

Primarily no activity

Light labor and light sports

Moderate labor and moderate sports

Full activities without restriction

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How do you look in clothes?

Very good

Good

Fair

Bad

Very bad

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In the past 6 months have you felt so down in the dumps that nothing could cheer you up?

Very often

Often

Sometimes

Rarely

Never

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Do you experience back pain when at rest?

Very often

Often

Sometimes

Rarely

Never

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What is your current level of work/school activity?

100% normal

75% normal

50% normal

25% normal

0% normal

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Which of the following best describes the appearance of your trunk; defined as the human body except for the head and extremities?

Very good

Good

Fair

Poor

Very Poor

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Which one of the following best describes your pain medication use for back pain?

None

Non-narcotics weekly or less (e.g., aspirin, Tylenol, Ibuprofen)

Non-narcotics daily

Narcotics weekly or less (e.g. Endone, Oxycontin orally or, Norspan , Durogesic patches)

Narcotics daily

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Does your back limit your ability to do things around the house?

Never

Rarely

Sometimes

Often

Very Often

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Have you felt calm and peaceful during the past 6 months?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

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Do you feel that your back condition affects your personal relationships?

None

Slightly

Mildly

Moderately

Severely

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Are you and/or your family experiencing financial difficulties because of your back?

Severely

Moderately

Mildly

Slightly

None

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In the past 6 months have you felt down hearted and blue?

Never

Rarely

Sometimes

Often

Very often

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In the last 3 months have you taken any days off of work, including household work, or school because of back pain?

0 days

1 day

2 days

3 days

4 or more days

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Does your back condition limit your going out with friends/family?

Never

Rarely

Sometimes

Often

Very often

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Do you feel attractive with your current back condition?

Yes, very

Yes, somewhat

Neither attractive nor unattractive

No, not very much

No, not at all

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Have you been a happy person during the past 6 months?

None of the time

A little of the time

Some of the time

Most of the time

All of the time

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Are you satisfied with the results of your back management?

Very satisfied

Satisfied

Neither satisfied nor unsatisfied

Unsatisfied

Very unsatisfied

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Would you have the same management again if you had the same condition?

Definitely yes

Probably yes

Not sure

Probably not

Definitely not

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Thank you for completing this questionnaire. Please comment if you wish.