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Form 5 -
Back problem form

Complete this form if you:

  • Have already been to Coogee Bay Physio (if not please complete form 1)

  • Have an issue with your upper or lower back including sciatica

About this form:

This questionnaire inquires about the way your back pain is affecting your daily life. It is based on the prescribed questions from the Quebec Back Pain Disability Scale (QBPDS).

People with back problems may find it difficult to perform some of their daily activities. We would like to know if you find it difficult to perform any of the activities listed below, because of your back problem.

Please choose one response option for each activity (all questions are required).

Your details
Name *
Name
Your main daytime contact number
Questions
1. Today, do you or would you have any difficulty at all with your usual work, housework or school activities? *
2. Today, do you or would you have any difficulty at all with your usual hobbies, recreational or sporting activities? *
3. Today, do you or would you have any difficulty at all with lifting a bag of groceries to waist level? *
4. Today, do you or would you have any difficulty at all with lifting a bag of groceries above your head? *
5. Today, do you or would you have any difficulty at all with grooming your hair? *
6. Today, do you or would you have any difficulty at all with pushing up from your hands (eg from bathtub to chair)? *
7. Today, do you or would you have any difficulty at all with preparing food (eg peeling, cutting)? *
8. Today, do you or would you have any difficulty at all with driving? *
9. Today, do you or would you have any difficulty at all with vacuuming, sweeping or raking?
10. Today, do you or would you have any difficulty at all with dressing? *
11. Today, do you or would you have any difficulty at all with doing up buttons? *
12. Today, do you or would you have any difficulty at all with using tools or appliances? *
13. Today, do you or would you have any difficulty at all with opening doors? *
14. Today, do you or would you have any difficulty at all with cleaning? *
15. Today, do you or would you have any difficulty at all with tying or lacing shoes? *
16. Today, do you or would you have any difficulty at all with sleeping? *
17. Today, do you or would you have any difficulty at all with laundering clothes (washing, ironing, folding)? *
18. Today, do you or would you have any difficulty at all with opening jar? *
19. Today, do you or would you have any difficulty at all with throwing a ball? *
20. Today, do you or would you have any difficulty at all with carrying a small suitcase with your affected limb? *
Thank you!
Thank you for your submission. it will form a valuable part of our ongoing assessment of your functional capacity as it relates to your upper limb problem.

To discuss further or learn more about our clinic and treatment options please don’t hesitate to get in touch with us by clicking here.

Or, call us on (02) 9665 9667 during business hours.

Index Source:
1.
Kopec, JA, Esdaile, JM, Abrahamowicz, M., Abenhaim, L, Wood-Dauphinee, S, Lamping, DL & Williams JI. (1995). The Quebec Back Pain Disability Scale. Spine, 20(3): 341-352.
2. Davidson, M. & Keating, J.L. (2002). A comparison of five low back disability questionnaires: Reliability and responsiveness. Physical Therapy, 82(1): 8- 24.