Back Injury Assessment Form
Please complete this form to help us assess your back injury symptoms and history.
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 Injury
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate the area(s) of your back where you experience pain:
*
Lower back
Middle back
Upper back
Neck
Other
Please rate your average pain level (0 = no pain, 10 = worst possible pain):
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
How would you describe your pain?
*
Sharp/stabbing
Dull/aching
Burning
Radiating
Tingling/numbness
Other
What activities make your pain worse or better?
Rows
Worse
Better
Sitting
1
2
Standing
3
4
Walking
5
6
Lifting
7
8
Resting
9
10
Bending
11
12
Please indicate how your back injury affects your daily activities:
*
Rows
No difficulty
Some difficulty
Unable to do
Getting out of bed
13
14
15
Climbing stairs
16
17
18
Carrying groceries
19
20
21
Personal hygiene
22
23
24
Driving
25
26
27
Work tasks
28
29
30
Have you experienced back injuries before?
*
Yes
No
Please list any treatments you have tried for your back injury (e.g., medication, physical therapy, rest):
Signature (please sign to confirm the information provided is accurate to the best of your knowledge):
*
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