The Orthopedic Center (Back Pain)

Patient Information

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.

Pain Assessment

* Required Information

*Pain Intensity

I have no pain at the moment.

The pain is very mild at the moment.

The pain is moderate at the moment.

The pain is fairly severe at the moment.

The pain is very severe at the moment.

The pain is the worst imaginable at the moment.

*Personal Care

I can look after myself normally without causing extra pain.

I can look after myself normally but it is very painful.

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, wash with difficulty and stay in bed.

*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 the floor, but I can manage if they are conveniently positioned, e.g. on a table.

Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned.

I can lift only very light weights.

I cannot lift or carry anything at all.

*Walking

Pain does not prevent me walking any distance.

Pain prevents me walking more than one mile.

Pain prevents me walking more than a quarter of a mile.

Pain prevents me walking more than 100 yards.

I can only walk using a stick or crutches.

I am in bed most of the time and have to crawl to the toilet.

*Sitting

I can sit in any chair for as long as I like.

I can sit in my favorite chair as long as I like.

Pain prevents me from sitting for more than 1 hour.

Pain prevents me from sitting for more than half an hour.

Pain prevents me from sitting for more than 10 minutes.

Pain prevents me from sitting at all.

*Standing

I can stand as long as I want without extra pain.

I can stand as long as I want but it gives me extra pain.

Pain prevents me from standing for more than 1 hour.

Pain prevents me from standing for more than half an hour.

Pain prevents me from standing for more than 10 minutes.

Pain prevents me from standing at all.

*Sleeping

My sleep is never disturbed by pain.

My sleep is occasionally disturbed by pain.

Because of pain I have less than 6 hours sleep.

Because of pain I have less than 4 hours sleep.

Because of pain I have less than 2 hours sleep.

Pain prevents me from sleeping at all.

*Sex Life

Not applicable.

My sex life is normal and causes no extra pain.

My sex life is normal but causes some extra pain.

My sex life is nearly normal but is very painful.

My sex life is severely restricted by pain.

My sex life is nearly absent because of pain.

Pain prevents any sex life at all.

*Social Life

My social life is normal and causes me no extra pain.

My social life is normal but increases the degree of pain.

Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. sport, etc.

Pain has restricted my social life and I do not go out as often.

Pain has restricted social life to my home.

I have no social life because of pain.

*Traveling

I can travel anywhere without pain.

I can travel anywhere but it gives extra pain.

Pain is bad but I manage journeys over two hours.

Pain restricts me to journeys of less than one hour.

Pain restricts me to short necessary journeys under 30 minutes.

Pain prevents me from traveling except to receive treatment.