Low Back

1.

Have you ever had low back trouble

(ache, pain, or discomfort)
1.
No
2.
Yes

8.

Have you had low back trouble at

any time during the last 7 days?
1.

If you answered no to question 1, do

not answer questions 2-8
2.

3.

4.

Have you ever been hospitalized

because of low back trouble?
1.
No
2.
Yes
Have you ever had to change jobs or
duties because of low back trouble?
1.
No
2.
Yes
What is the total length of time that
you have had low back trouble during
the last 12 months?
1.
0 days
2.
1-7 days
3.
8-30 days
4.
More than 30 days, but not
everyday
5.
Everyday
If you answered 0 days to question 4,
do not answer questions 5-8

5.

Has low back trouble caused you to

reduce your activity during last 12
months?
a. Work activity (at home or away from
home)
1.
No
2.
Yes
b.

6.

7.

Leisure activity?
1.
No
2.

Yes

What is the total length of time that

low back trouble has prevented you
from doing your normal work (at home
or away from home) during the past 12
months?
1.
0 days
2.
1-7 days
3.
8-30 days
4.
More than 30 days
Have you been seen by a doctor,
physiotherapist, chiropractor, or
other such person because of low
back trouble during the last 12

No

2.

Yes