Back Disability Form

Lower back pain isn’t just a frequent issue, but may result in disability. It becomes an essential cause associated with disability as well as decline in the workforce. Lower back pain can impact activities involving everyday living resulting in substantial medical expenditures and reduces the capability to work. It is essential to produce an analysis of the degree of self rated impairment and this particular form may help.

This form is based a disability questionnaire by Roland Morris. It uses similar questioning, however, the descriptive scoring represents a division into named levels of disability that the original questionnaire does not. So, you will get the score of your disability according to the original disability questionnaire, although, the description of how disabled you are is not based on the original questionnaire or any studies related to it.

The basis of the questionnaire is to determine a baseline score or reference from the 24 questions. The scoring is then used to determine a place whereby disability progression or regression can be determined throughout a course of time.

This particular back disability questionnaire was established to assist in understanding just how back pain affects ones capability to handle day-to-day activities. Whenever your lower back is painful, you might find it challenging to be able to perform things you typically do. Simply indicate yes when it identifies your situation at this time. In the event that it really does, tag “YES”, otherwise, indicate “NO”.

After answering ALL of the questions, click on the ‘Score‘ button and a new window will open up with the Back Disability Score along with an interpretation based on a division of scoring. You may return at a later date to see if your disability score has improved or is getting worse.

Due to my back condition, I remain at home most of the time.

YES – NO


To get my back more comfortable, I shift positions often.

YES – NO


My back condition causes me to walk slow.

YES – NO


My back does not allow me to do normal jobs around the home.

YES – NO


My back condition forces me to use a handrail going up stairs.

YES – NO


I have to lie down more frquently due to my back.

YES – NO


Due to my lower back, I must grab something to help get up from a low chair.

YES – NO


Due to my back condition, I try getting others to do things for me.

YES – NO


My back causes me to get dressed slowly.

YES – NO


My back problem only permits me to stand for short periods of tome.

YES – NO


My back makes it difficult to bend or kneel.

YES – NO


It is difficult to get out of any chair due to my back.

YES – NO


Due to my back, I am in pain most of the time.

YES – NO


Back pain makes it hard to turn over in bed.

YES – NO


My back condition makes my appetite worse.

YES – NO


Back pain causes me difficulty in putting on socks/stockings.

YES – NO


Back pain prevents me from walking longer distances.

YES – NO


My back pain causes me to lose sleep.

YES – NO


I need help getting dressed due to my back pain.

YES – NO


Du to my back condition, I sit most of the day.

YES – NO


Because of my back, I can’t do heavy jobs around my home.

YES – NO


My back condition causes me to lose my temper more and become more irritable.

YES – NO


Back pain causes me to go up stairs slowly.

YES – NO


I have to stay in bed most of the day due to back pain.

YES – NO


 

 

 

This Back Disability Questionnaire is really a way of measuring that’s made to be performed by individuals in evaluation regarding disability associated with lower back pain. Intended for utilization in research being an outcome measure regarding scientific studies, it’s been beneficial in order to keep track of individuals within a clinical environment.

The score you get from the online form is based on the 24 item questionnaire, it is not meant to provide a descriptive account of disability status. It pertinent for observing short-term changes in back pain – resolution or worsening of symptoms of patients seen in a clinical settings as well as responses to treatment(s). The scores range from 0 (no disability) to 24 (maximum disability). In this online form, the scores are weighted by division into 6 categories.