Back Bournemouth Questionnaire

Legal Name*
First Name Last Name
Patient ID#*
Date
Date Format: MM slash DD slash YYYY
Clinic Location*
Over the past week, on average, how would you rate your back pain?
Over the past week, how much has your back pain interfered with your daily activities (housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)?
Over the past week, how much has your back pain interfered with your ability to take part in recreational, social, and family activities?
Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have you been feeling?
Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling?
Over the past week, how have you felt your work (both inside and outside the home) has affected (or would affect) your back pain?
Over the past week, how much have you been able to control (reduce/help) your back pain on your own?
PEG Assessment
What number best describes your pain on average in the past week?
What number best describes how, during the past week, pain has interfered with your enjoyment of life?
What number best describes how, during the past week, pain has interfered with your general activity?
Verify*
- I acknowledge that this information is true and correct.

How can Tuck Chiropractic help you?

Whether you just want a better health lifestyle or you need relief from intense or chronic pain, we can help.

I Want A Better Lifestyle I'm In Pain Right Now

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