3D Spine Simulator


Launch 3D Spine Simulator

Please print & bring this questionaire with you to your visit to find out & discuss your score with our practitioners.
 
Please check off the choice that best describes your Back Pain:
 
1 - Pain Intensity
I can tolerate the pain without having to use painkillers.
The pain is bad but I can manage without taking painkillers.
Painkillers give complete relief from pain.
Painkillers give moderate relief from pain.
Painkillers give very little relief from pain.
Painkillers have no effect on the pain and I do not use them.

2 - Personal Care
I can look after myself normally without causing extra pain.
I can look after myself normally but it caused extra pain.
It is painful to look after myself and I am slow and careful.
I need some help but manage most of my personal care.
I need help every day in most aspects of self-care.
I do not get dressed; I wash with difficulty and stay in bed.

3 - Lifting
I can lift heavy weight without extra pain.
I can lift heavy weights but it gives extra pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (on a table etc.).
I can lift light to moderate weights.
I can lift very light weights.
I cannot lift or carry anything at all.

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 one- half mile.
Pain prevents me from walking more than one- quarter mile.
I can only walk using a stick or crutches.
I am in bed most of the time and have to crawl to the toilet.

5 - Sitting
I can sit in any chair as long as I like.
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 30 minutes.
Pain prevents me from sitting more than 10 minutes.
Pain prevents me from sitting almost all the time.

6 - Standing
I can stand as long as I want without extra pain.
I can stand as long as I want but it gives extra pain.
Pain prevents me from standing for more than 1 hour.
Pain prevents me from standing for more than 30 minutes.
Pain prevents me from standing for more than 10 minutes.
Pain prevents me from standing at all.

7 - Sleeping
Pain does not prevent me from sleeping at all.
I can sleep well only by using tablets.
Even when I take tablets I have less than 8 hours to sleep.
Even when I take tablets I have less than 4 hours to sleep.
Even when I take tablets I have less than 2 hours to sleep.
Pain prevents me from sleeping at all.

8 - Social life
My social life is normal and gives no extra pain.
My social life is normal but it increases the degree of pain.
Pain has no significant effevt on my social life apart from limiting my more energetic interests, e.g. dancing.
Pain has restricted my social life and I do not go out as often.
Pain has restricted my social life to home.
I have no social life because of pain.

9 - Traveling
I can travel everywhere without extra pain.
I can travel everywhere but it gives extra pain.
Pain is bad but I manage journeys over 2 hours.
Pain is bad but I manage journeys of less than 1 hour.
Pain restricts me to short necessary journeys under 30 minutes.
Pain prevents me from traveling except to the doctor or hospital.

10 - Changing Degree of Pain
My pain is rapidly getting better.
My pain fluctuates but overall is definately getting better.
My pain seems to be getting better but improvement is slow at the present.
My pain is neither getting better nor worse.
My pain is gradually worsening.
My pain is rapidly worsening.