Low Back Disability Questionnaire
This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box which most closely describes your problem.
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Email *
Your Name *
Your Physical Therapist
Section 1 — Pain Intensity *
Section 2 — Personal Care (Washing, Dressing, etc.) *
Section 3 — Lifting *
Section 4 — Walking *
Section 5 — Sitting *
Section 6 — Standing *
Section 7 — Sleeping *
Section 8 — Social Life *
Section 9 — Traveling *
Section 10 — Changing Degree of Pain *
Any comments to add?
Calculate Your %ADL: Questions are scored on a vertical scale of 0-5. Total scores above and multiply by 2. Divide by number of sections answered multiplied by 10.  (A score of 22% or more is considered significant activities of daily living disability) *
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