This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by checking ONE box in each section for the statement which best applies to you. We realise you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem.

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: Sex life (if applicable)

Section 9: Social life

Section 10: Travelling