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).
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.
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.