ONGOING BACK PAIN RISK
35 Questions that predict ongoing back pain
Click on one button each line for your response to the questions below

Click here to download a printable PDF file that you can complete.
Take it with you to your chiropractor for advice about reducing your risk factors.
Main Questions
Do you now have back pain that has lasted for 4 or more days without easing?
Yes
No
 
Have you ever suffered pain going down the back of your leg(s) or any symptoms into your feet (like numbness or pins and needles)?
Yes
No
 
Do you suffer from mild attacks of back pain that usually go away within less than 4 days (over the last 5 years)?
Yes
No
 
Have you ever suffered a back injury before (pain lasting more than 2 weeks)?
Yes
No
 
Are you female with 2 or more children?
Yes
No
 
Are you aged between 45 and 65 years?
Yes
No
 
Do you presently smoke?
Yes
No
 
Are you now overweight?
Yes
No
 
Do you presently participate in any contact sports?
Yes
No
 
Do you exercise less than 3 times per week? (moderate level of 1 hour duration)
Yes
No
 
Would you be in more pain if you increased your exercise levels?
Yes
No
 
Does your work or home life involve standing for long periods?
Yes
No
 
Does your work or home life involve sitting for long periods?
Yes
No
 
If you sit for longer than 30 minutes do you have to move about because your back is uncomfortable?
Yes
No
 
If you sit for longer than 30 minutes do you get back or leg pain?
Yes
No
 
If you do any activity requiring prolonged bending (like gardening), do you feel pain or stiffness across your lower back?
Yes
No
 
Does your work or home-life involve lots of heavy or repetitive lifting?
Yes
No
 
Does any activity you do involve vibrations whilst sitting?
Yes
No
 
Does your work or home life involve using vibrating tools for extended periods?
Yes
No
 
When you cough or sneeze, do you feel a jab of pain in your back?
Yes
No
 
Is your bed more than 10 years old?
Yes
No
 
Do you sleep on your stomach?
Yes
No
 
Do you wake with stiffness or pain in your back regularly?
Yes
No
 
Does a directly related family member also suffer from back pain?
Yes
No
 
Do you consume more than 7 glasses of wine, or 7 cans of beer per week?
Yes
No
 
Is it more than 12 months since you have taken holidays of more than 5 days?
Yes
No
 
When you are in pain, does this indicate to you that the pain is causing you more damage?
Yes
No
 
Do you feel that you are currently under significant psychological stress?
Yes
No
 
Does your work involve meaningless repetitive tasks for most of your day?
Yes
No
 
Do you use drugs of any sort to help you relax or to cope with life?
Yes
No
 
Is there a compensation claim or other legal matter pending in relation to yourself or a close family member?
Yes
No
 
Are you dissatisfied with your current work or home environment?
Yes
No
 
Are you presently unemployed?
Yes
No
 
Have you ever been told you have scoliosis?
Yes
No
 
Have you ever been told you suffer from osteoporosis?
Yes
No
 
Personal Details
Email Address
 
The best telephone number to contact me at is
 
Please contact me to arrange an appointment
Yes
No
 
Comments
 

 

Yes responses Risk of back pain
1-5 MILD
6-10 MODERATE
More than 10 HIGH

For direct contact with our staff during business hours ring
+61(8) 9361-2628.

Click here to download a printable PDF file that you can complete.
Take it with you to your chiropractor for advice about reducing your risk factors.
 
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