Postpartum Back Pain Assessment Form
Please complete this assessment to help us understand your postpartum back pain and how it affects your daily life.
How many weeks postpartum are you?
*
How would you rate your current back pain?
*
1
2
3
4
5
6
7
8
9
10
Where is your back pain located?
*
Lower back
Middle back
Upper back
Radiating to legs
Other
How long have you been experiencing this back pain?
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Which activities make your back pain worse?
*
Lifting/carrying baby
Household chores
Sitting for long periods
Standing/walking
Other
Which activities help relieve your back pain?
Resting
Stretching/exercise
Heat/cold therapy
Pain medication
Other
How much does your back pain affect your ability to perform daily activities?
*
Not at all
0
1
2
3
4
5
6
7
8
9
Completely prevents
10
0 is Not at all, 10 is Completely prevents
Please rate the impact of back pain on the following aspects:
*
Rows
No impact
Mild
Moderate
Severe
Sleep quality
1
2
3
4
Mood
5
6
7
8
Ability to care for baby
9
10
11
12
Mobility
13
14
15
16
Have you experienced any numbness, tingling, or weakness in your legs?
*
No
Yes
Submit Assessment
Should be Empty: