Chapman Back Pain Survey

Back Pain Pre Exam Form
Chapman Location

For patients experiencing any kind of pain or injury in the low/mid/upper back. Please fill out to the best of your ability and submit.

** This survey is meant to help us obtain information from you regarding your current levels of discomfort and capability.

* Indicates required field

Name *

First

Last

On the following, please mark the most appropriate response about your pain level with the following activities *

1. PAIN INTENSITY *

I can tolerate the pain I have without having to use pain medication. The pain is bad, but I can manage without having to take pain medication Pain medication provides me with complete relief from pain. Pain medication provides me with moderate relief from pain. Pain medication provides me with little relief from pain. Pain medication has no effect on my pain.

2. PERSONAL CARE (washing, dressing, etc.) *

I can look after myself normally without causing increased pain I can look after myself normally but it increases my pain. It is painful to look after myself and I am slow and careful. I need help, but I am able to manage most of my personal care. I need help every day in most aspects of my care. I do not get dressed, wash with difficulty and stay in bed

3. LIFTING *

I can lift heavy weights without increased pain. I can lift heavy weights but it causes me increased pain. Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned. (i.e. 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.

4. WALKING *

Pain does not prevent me from walking any distance. Pain prevents me from walking more than 1 mile. Pain prevents me from walking more than 1/2 mile. Pain prevents me from walking more than 1/4 mile. I can only walk with crutches or a cane. 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 1 hour. Pain prevents me from sitting more than 1/2 hour. Pain prevents me from sitting more than 10 minutes. Pain prevents me from sitting at all.

6. STANDING *

I can stand as long as I want without increased pain. I can stand as long as I want but it increases my pain. Pain prevents me from standing more than 1 hour. Pain prevents me from standing more than 1/2 hour. Pain prevents me from standing more than 10 minutes. Pain prevents me from standing at all.

7. SLEEPING *

Pain does not prevent me from sleeping well. I can sleep well only by using pain medication. Even when I take pain medication, I sleep less than 6 hours. Even when I take pain medication, I sleep less than 4 hours. Even when I take pain medication, I sleep less than 2 hours. Pain prevents me from sleeping at all.

8. SOCIAL LIFE *

My social life is normal and does not increase my pain. My social life is normal, but it increases my level of pain. Pain prevents me from particiapting in more energetic activities (eg. sports, dancing). Pain prevents me from going out very often. Pain has restricted my social life to my home. I have hardly any social life because of my pain.

9. TRAVELING *

I can travel anywhere without increased pain. I can travel anywhere, but it increases my pain. My pain restricts my travel over 2 hour. My pain restricts my travel over 1 hour. My pain restricts my travel to short necessary journeys - journeys under 1/2 hour. My pain prevents all travel except for visits to the physician/therapist or hospital

10. EMPLOYMENT/HOMEMAKING *

My normal homemaking/job activities do not cause pain. My normal homemaking/job activities increase my pain, but I can still perform all that is required of me. I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (eg, lifting, vacuuming) Pain prevents me from doing anything but light duties. Pain prevents me from doing even light duties. Pain prevents me from performing any job or homemaking chores.

Submit

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.

Now With 2 Locations to Better Serve You!

103 Northwest 15th Street
Abilene, KS 67410
Phone: 785-263-3646
FAX: 785-263-3689

HOURS:
Monday - Friday
8:00 a.m - 5:00 p.m.

1030 North Marshall, Suite B
Chapman, KS 67431
Phone: 785-922-4016
FAX: 785-922-4018

HOURS:
Monday - 1 p.m. - 5 p.m.
Tuesday & Thursday 8 a.m. - 5 p.m.

** This survey is meant to help us obtain information from you regarding your current levels of discomfort and capability.

The state of Kansas is a “Direct Access” state for Physical Therapy. ​ You can begin physical therapy with or without a referral from a physician. ​

Now With 2 Locations to Better Serve You!

Contact Us

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.