A number of things can cause back trouble. This simple questionnaire can help provide important clues to what's at the root of your back problem. Answer as many questions as you can and take a copy of this section to your doctor when your back needs medical attention.
1. Do you have a history of back problems? _________________________________
2. What is the major complaint?___________________________________________
3. When did the pain, stiffness, or symptoms begin? ____________________________
___________________________________________________________________
4. Did it begin gradually or suddenly? _______________________________________
5. Were you sick in any way when it began?__________________________________
6. Do these symptoms disturb or prevent sleep (awaken you with pain)?_____________
___________________________________________________________________
7. Is this the first experience of this kind?_____________________________________
8. Is the pain unrelenting?________________________________________________
9. Is the pain intermittent?________________________________________________
10. Is the pain sharp, dull, burning, aching, cramping, or shooting? _________________
____________________________________________________________________
11. What do you suspect the problem was caused by? Check all that apply.
__ injury
__ overweight
__ poor posture
__ stress/tension
__ menstruation
__ illness
__ pregnancy
__ overexertion
__ other (explain) _______________________________________________________
12. When does the problem annoy you the most? Check all that apply.
__ at work
__ when lifting
__ when in bed
__ when bending
__ when stressed
__ when fatigued
__ when coughing or sneezing
__ when sitting
__ when standing
__ when driving
__ when carrying
__ in the morning
__ in the afternoon
__ in the evening
__ other (explain) _______________________________________________________
13. Does the pain radiate or move in a particular direction? If yes, explain. _____________
_____________________________________________________________________
14. Do you experience muscle spasms?_______________________________________
15. Do you sleep on a soft mattress or a hard one?_______________________________
16. Have you been under nervous or emotional strain lately?________________________
17. Is there any redness, tenderness, or swelling?_________________________________
18. Is there a daily pattern to the pain?_________________________________________
19. What helps relieve the pain? Check all that apply
__ heart
__ ice packs
__ exercise
__ bed rest
__ hot baths
__ muscle relaxants
__ massage
__ brace
__ walking
__ painkillers
__ nothing
__ haven't tried anything
20. Are there any other factors that the doctor should be aware of?
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