This questionnaire is about the way your back pain is affecting your daily life. People with back problems may find it difficult to perform some of their daily activities.
  • Name*full name
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  • Email*a valid email address
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  • We would like to know if you find it difficult to perform any of the activities listed below, because of your back. For each activity there is a scale of 0 to 5. Please choose one response option for each activity (do not skip any activities) and circle the corresponding number. Today, do you find it difficult to perform the following activities because of your back?
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  • 1. Get out of bed*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
    3
  • 2. Sleep through the night*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
    4
  • 3. Turn over in bed*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
    5
  • 4. Ride in a car*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
    6
  • 5. Stand up for 20-30 minutes*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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  • 6. Sit in a chair for several hours*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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  • 7. Climb one flight of stairs*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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  • 8. Walk a few blocks (300-400 m)*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
    10
  • 9. Walk several kilometres*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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  • 10. Reach up to high shelves*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
    12
  • 11. Throw a ball*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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  • 12. Run one block (about 100m)*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
    14
  • 13. Take food out of the refrigerator*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
    15
  • 14. Make your bed*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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  • 15. Put on socks (pantyhose)*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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  • 16. Bend over to clean the bathtub*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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  • 17. Move a chair*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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  • 18. Pull or push heavy doors*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
    20
  • 19. Carry two bags of groceries*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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  • 20. Lift and carry a heavy suitcase*select just one
    0 Not difficult at all
    1 Minimally difficult
    2 Somewhat difficult
    3 Fairly difficult
    4 Very difficult
    5 Unable to do
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