Cleveland Biophysics - Lower Back Questionaire

Office Hours:

Monday:

9:00a - 12:30p
3:00p - 6:30p

Tuesday:

3:00p - 6:30p

Wednesday:

9:00a - 12:30p
3:00p - 6:30p

Thursday:

3:00p - 6:30p

Friday:

9:00a - 12:30p

Saturday:

8:30a - 11:00a

Lower Back Function Questionnaire
Curious to see if your health problems are affecting your daily life? The following 10 questions are the most proven way to answer that question.
Simply click one answer that best fits. If 2 choices fit, pick the worst. Each question must be answered.

Section 1- Pain Intensity The pain comes and goes and is very mild. The pain is mild and does not vary much. The pain comes and goes and is moderate. The pain is moderate and does not vary much. The pain comes and goes and is severe. The pain is severe and does not vary much.	Section 6- Standing I can stand as long as I want without pain. I have some pain while standing, but it does not increase. I cannot stand for longer than an hour without more pain. I cannot stand for longer than ½ hour without more pain. I cannot stand for longer than ten minutes without pain. I avoid standing because it increases my pain right away.

Section 2- Personal Care (Washing, Dressing, etc.) I do not have to change my personal care in order to avoid pain. I do not normally have to change my personal care even though it causes some pain. Personal care increases the pain, but I manage no change to my way of doing it. Personal care increases the pain; I find it necessary to change my way of doing it. Because of the pain, I am unable to do some personal care without help. Due to the pain, I am unable to do personal care without help.	Section 7- Sleeping I get no pain in bed. I get pain in bed, but it doesn’t prevent me from sleeping. Due to pain, my normal night’s sleep is reduced by less than one-quarter. Due to pain, my normal night’s sleep is reduced by less than one-half. Due to pain, my normal night’s sleep is reduced by less than three-quarters. Pain prevents me from sleeping at all.

Section 3- Lifting I can lift heavy weights without extra pain. I can lift heavy weights, but it gives extra pain. Pain prevents me from lifting heavy weights off of the floor. Pain prevents heavy lifting, unless in elevated position. I can manage light to medium weight if in elevated position. I can only lift very light weights at most.	Section 8- Social Life My social life is normal and gives me no pain. My social life is normal, but increases the degree of my pain. Pain has no significant effect on my social life apart from limiting my more energetic interests (such as dancing). Pain has restricted my social life and I do not go out very often. Pain has restricted my social life to my home. I hardly have a social life due to my pain.

Section 4- Walking Pain does not prevent me from walking any distance. Pain prevents me from walking more than one mile. Pain prevents me from walking more than ½ mile. Pain prevents me from walking more than ¼ mile. I can only walk while using a cane or on crutches. I am in bed most of the time and have to crawl to the toilet.	Section 9- Traveling I get no pain while traveling. I get some pain traveling, but traveling does not make the pain worse. I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. I get extra pain while traveling which compels me to seek alternative forms of travel. Pain restricts all forms of travel. Pain prevents all forms of travel except when lying down.

Section 5- Sitting I can sit in any chair as long as I like without pain. I can only sit in my favorite chair as long as I like. Pain prevents me from sitting more than one hour. Pain prevents me from sitting more than ½ hour. Pain prevents me from sitting more than ten minutes. Pain prevents me from sitting at all.	Section 10- Changing Degree of Pain My pain is rapidly getting better. My pain fluctuates, but overall is definitely getting better. My pain seems to be getting better, but improvement is slow. My pain is neither getting better nor worse. My pain is gradually worsening.

Cleveland Biophysics, LLC
7050 Engle Rd.
Suite 101
Middleburg Heights, OH 44130

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