Complete Chiropractic – Low back pain disability index Low back pain disability indexThis low back disability index form should be used if you have been directed to do so by your doctor.Part 1 About youYour Prefix *Mr.Mrs.Ms.Mx.MissDr.Prof.Your First Name *Your Last Name *Email Address *Section 2 Your back pain This questionnaire is designed to enable us to understand how much your low back pain has affected your ability to manage your everyday activities. Please answer each section by selecting the one choice that most applies to you. We realise that you may feel that more than one statement may relate to you, but please choose just the one which fits best.How does your back pain impact you? Pain intensity *A. The pain comes and goes and is very mild.B. The pain is mild and does not vary much.C. The pain comes and goes and is moderate.D. The pain is moderate and does not vary much.E. The pain comes and goes and is severe.F. The pain is severe and does not vary much.Personal Care *A. I would not have to change my way of washing or dressing in order to avoid pain.B. I do not normally change my way of washing or dressing even though it causes some pain.C. Washing and dressing increases the pain, but I manage not to change my way of doing it.D. Washing and dressing increases the pain and I find it necessary to change my way of doing it.E. Because of the pain, I am unable to do some washing and dressing without help.F. Because of the pain, I am unable to wash or dress without help.Lifting *A. I can lift heavy weights without extra pain.B. I can lift heavy weights, but it causes extra pain.C. Pain prevents me from lifting heavy weight off the floor.D. Pain prevents me from lifting heavy weight off the floor....but I can manage if they are conveniently positioned, eg. on a table.E. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.F. I can only lift very light weights, at the most.Walking *A. Pain does not prevent me from walking any distance.B. Pain prevents me from walking more than one mile.C. Pain prevents me from walking more than ½ mile.D. Pain prevents me from walking more than ¼ mileE. I can only walk while using a cane or on crutches.F. I am in bed most of the time and have to crawl to the toiletSitting *A. I can sit in any chair as long as I like without pain.B. I can only sit in my favourite chair as long as I like.C. Pain prevents me from sitting more than one hour.D. Pain prevents me from sitting more than ½ hour.E. Pain prevents me from sitting more than ten minutes.F. Pain prevents me from sitting at all.Standing *A. I can stand as long as I want without pain.B. I have some pain while standing, but it does not increase with time.C. I cannot stand for longer than one hour without increasing pain.D. I cannot stand for longer than ½ hour without increasing pain.E. I cannot stand for longer than ten minute without increasing pain.F. I avoid standing, because it increases the pain straight away.Sleeping *A. I get no pain in bed.B. I get pain in bed, but it does not prevent me from sleeping well.C. Because of pain, my normal night’s sleep is reduced by less than one quarter.D. Because of pain, my normal night’s sleep is reduced by less than one-half.E. Because of pain, my normal night’s sleep is reduced by less than three-quarters.F. Pain prevents me from sleeping at all.Social life *A. My social life is normal and give me no pain.B. My social life is normal, but increases the degree of my pain.C. Pain has no significant effect on my social life apart from limiting my more energetic interests, My dancing, etc.D. Pain has restricted my social life and I do not go out very often.E. Pain has restricted my social life to my home.F. I have hardly any social life because of the pain.Travelling *A. I get no pain while traveling.B. I get some pain while traveling, but none of my usual forms of travel make it any worse.C. I get extra pain while traveling, but it does not compel me to seek alternative forms of travel.D. I get extra pain while traveling which compels me to seek alternative forms of travel.E. Pain restricts all forms of travel.F. Pain prevents all forms of travel except that done lying down.Changing degree of pain *A. My pain is rapidly getting better.B. My pain fluctuates, but overall is definitely getting better.C. My pain seems to be getting better, but improvement is slow at present.D. My pain is neither getting better nor worse.E. My pain is gradually worsening.F. My pain is rapidly worsening.Thank you for completing the low back disability form. Please check the box below to indicate you have read our privacy policy and then press "Submit".GDPR *Yes, I agree with privacy policy, terms and conditionSubmit formPlease do not fill in this field.
