Back Pain Functional Scale Questionnaire
Please rate your ability to perform the following activities. This questionnaire helps assess how back pain may be affecting your daily life.
Full Name
First Name
Last Name
How well can you perform personal care activities (e.g., washing, dressing)?
*
Unable to perform
0
1
2
3
4
5
6
7
8
9
No difficulty
10
0 is Unable to perform, 10 is No difficulty
How well can you lift and carry objects?
*
Unable to perform
0
1
2
3
4
5
6
7
8
9
No difficulty
10
0 is Unable to perform, 10 is No difficulty
How well can you walk short distances (up to 100 meters)?
*
Unable to perform
0
1
2
3
4
5
6
7
8
9
No difficulty
10
0 is Unable to perform, 10 is No difficulty
How well can you sit for 30 minutes?
*
Unable to perform
0
1
2
3
4
5
6
7
8
9
No difficulty
10
0 is Unable to perform, 10 is No difficulty
How well can you stand for 30 minutes?
*
Unable to perform
0
1
2
3
4
5
6
7
8
9
No difficulty
10
0 is Unable to perform, 10 is No difficulty
How well can you climb stairs?
*
Unable to perform
0
1
2
3
4
5
6
7
8
9
No difficulty
10
0 is Unable to perform, 10 is No difficulty
How well can you sleep due to back pain?
*
Unable to sleep
0
1
2
3
4
5
6
7
8
9
No difficulty sleeping
10
0 is Unable to sleep, 10 is No difficulty sleeping
How well can you participate in work or household activities?
*
Unable to participate
0
1
2
3
4
5
6
7
8
9
No difficulty
10
0 is Unable to participate, 10 is No difficulty
Additional comments (optional)
Submit Questionnaire
Should be Empty: