Back Pain Screening

Preferred title

Male/Female

Main symptoms (closest match)

ACKNOWLEDGE: If you have any combination of these symptoms (2 or more) then you may be at risk of Cauda Equina Syndrome (CES) and should present to A&E or call 999 to be assessed and you may require an emergency MRI scan.

Are you experiencing any of these other symptoms (if multiple, choose the most severe)

Where are you experiencing the most of your main symptoms?

How long have you had your main symptoms?

How have your symptoms changed over time?

When are your symptoms at their worst?

When are your symptoms better?

Do you know what first caused your symptoms?

Have you had any of the following medical exams or tests? (Please choose the most relavent)

When was this?

...and what was found?

Are you taking any medication for your symptoms?

Is there anything else you would like to add that you think might be relevant?

Would you prefer to manage this yourself with standard advice or have an in depth assessment?

Do you have a preference for chiropractic, osteopathy or physiotherapy?

How do you feel about having manual therapy (spinal manipulation, mobilisation or massage)

Would you be open to having a talking therapy if recommended?

Would you like help to get more active if recommended?

How many of the following statements are true?

My back pain has spread down my leg(s) at some time in the last 2 weeks

I have had pain in the shoulder or neck at some time in the last 2 weeks

I have only walked short distances because of my back pain

In the last 2 weeks, I have dressed more slowly than usual because of back pain

It’s not really safe for a person with a condition like mine to be physically active

Worrying thoughts have been going through my mind a lot of the time

I feel that my back pain is terrible and it’s never going to get any better

In general I have not enjoyed all the things I used to enjoy

Overall, how bothesome has your back pan been in the last 2 weeks?

Over the past week, on average, out of 10 (where 0 is good and 10 is bad):

How high would you rate your back pain?

how much has your back pain interfered with your daily activities (housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)?

how much has your back pain interfered with your ability to take part in recreational, social, and family activities?

how tense, uptight, irritable, difficulty in concentrating/relaxing have you been feeling?

how down-in-the-dumps, sad, in low spirits, pessimistic, unhappy have you been feeling?

how have you felt your work (both inside and outside the home) has affected (or would affect) your back pain?

how much have you been able to control (reduce/help) your back pain on your own? (0 = total control, 10 = no control)

Thanks. Now book your free 15 min Telehealth appointment to discuss your results.

Back Pain Screening

​Over the past week, on average, out of 10 (where 0 is good and 10 is bad):

Over the past week, on average, out of 10 (where 0 is good and 10 is bad):