Back Disability Index Questionnaire

Complete the questionnaire below as to how your back pain has affected your ability to manage in everyday life. Please make just ONE response in each section which most closely describes your problem:

Name:

Required Field

Email Address:

Required Field

Date of Birth:

Required Field

Appointment Date:

Required Field

SURGERY: If you have had surgery, are you pleased with the results and would you recommend the procedure to others:

(If Applicable)

SECTION 1 Pain Intensity:

Required Field

SECTION 2 Personal Care (washing, dress):

Required Field

SECTION 3 - Lifting:

Required Field

SECTION 4 - Walking:

Required Field

SECTION 5 - Sitting:

Required Field

SECTION 6 - Standing:

Required Field

SECTION 7 - Sleeping:

Required Field

SECTION 8 - Sex Life:

(If Applicable)

SECTION 9 - Social Life:

Required Field

SECTION 10 -Traveling:

Required Field