Scoliosis Quality of Life Questionnaire
Please complete this form to assess the impact of scoliosis on your daily life. Your responses will help your healthcare provider better understand your health and well-being.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
example@example.com
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate the following statements based on your experiences over the past week. Select the option that best describes your situation for each item.
*
Rows
Never
Rarely
Sometimes
Often
Always
I experience back pain.
1
2
3
4
5
I feel discomfort when sitting for long periods.
6
7
8
9
10
I find it difficult to participate in physical activities.
11
12
13
14
15
I am self-conscious about my appearance due to scoliosis.
16
17
18
19
20
I feel anxious or worried about my condition.
21
22
23
24
25
I have difficulty sleeping because of discomfort.
26
27
28
29
30
I need help with daily activities.
31
32
33
34
35
I avoid social situations because of my back.
36
37
38
39
40
I am satisfied with my current treatment.
41
42
43
44
45
I feel my quality of life is affected by scoliosis.
46
47
48
49
50
Please rate your overall quality of life related to scoliosis.
*
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
How satisfied are you with your current treatment or management plan?
*
1
2
3
4
5
Additional Comments (optional)
Would you like to discuss any specific concerns with your healthcare provider?
Yes
No
If yes, please specify your concerns below:
Submit Assessment
Should be Empty: