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| Question | Options | Description |
|---|---|---|
| I feel that my back pain is terrible and it's never going to get any better | ["Agree","Disagree"] | STarTBack #7 |
| Abdominal Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Abdominal Pain VAS Left/Right | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Aching muscles | ["yes","no"] | Aching muscles |
| admin custom | ["a","b","c","d","e","f","g","h","i","j"] | ad |
| admin head axial | ["yes","no"] | a |
| admin head bilateral | ["yes","no"] | b |
| Admin input 0-10 | ["0","1","2","3","4","5","6","7","8","9","10"] | 10 |
| Admin neck B | ["yes","no"] | cs |
| Admin pass fail | ["yes","no"] | admin only |
| An increase in pain is an indication that I should stop what I am doing until the pain decreases. | ["Completely Disagree - 0","1","2","3","4","5","6","7","8","9","Completely Agree - 10"] | An increase in pain |
| Anemia | ["yes","no"] | Anemia |
| Anemia | ["yes","no"] | Anemia |
| Ankle pain | ["yes","no"] | Ankle pain |
| Ankle Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Any of your usual work, housework, or school activities. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #1 |
| Are you able to run 100 yards? | ["Not at all","Very Little","Somewhat","Quite a lot","Cannot do","a","b","c","d","e"] | Promis Global Health |
| Are you able to run 100 yards? | ["Not at all","Very Little","Somewhat","Quite a lot","Cannot do","a","b","c","d","e"] | Promis Global Health |
| Are you able to run at a fast pace for two miles? | ["Not at all","Very Little","Somewhat","Quite a lot","Cannot do","a","b","c","d","e"] | Promis Global Health |
| Are you able to run five miles? | ["Not at all","Very Little","Somewhat","Quite a lot","Cannot do","a","b","c","d","e"] | Promis Global Health |
| Are you able to run or jog for two miles? | ["Not at all","Very Little","Somewhat","Quite a lot","Cannot do","a","b","c","d","e"] | Promis Global Health |
| Are you able to run ten miles? | ["Not at all","Very Little","Somewhat","Quite a lot","Cannot do","a","b","c","d","e"] | Promis Global Health |
| Atrial Fibrillation | ["yes","no"] | Atrial Firbrilation |
| Back pain | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Becoming easily annoyed or irritable | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Being so restless that it is hard to sit still | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Bend over to clean the bathtub | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Bladder problems | ["yes","no"] | Bladder problems |
| Bleeding Disorder | ["yes","no"] | Bleeding Disorder. |
| Blood Clots | ["yes","no"] | A thrombus, colloqui |
| Blood in stool | ["yes","no"] | Blood in stool/ |
| Calcaneal Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Cancer | ["yes","no"] | Have you had cancer? |
| Carry a shopping bag or briefcase. | ["No difficulty","Mild difficulty","Moderate difficulty","Severe difficulty","Unable"] | QucikDASH#3 |
| Carry two bags of groveries | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Changes in sex drive | ["yes","no"] | Changes in sex drive |
| Chest pain | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Chest Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Chills | ["yes","no"] | Chills is a feeling |
| Climb one flight of stairs | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Compared to one year ago, how would you rate your health in general now? | ["Much better now than one year ago","Somewhat better now than one year ago","About the same","Somewhat worse now than one year ago","Much worse than one year ago"] | SF-36 Much be |
| Concentration | ["I can concentrate fully when I want to with no difficulty","I can concentrate fully when I want to with slight difficulty","I have a fair degree of difficulty in concentrating when I want to","I have a lot of difficulty in concentrating when I want to"," I have a great deal of difficulty in concentrating when I want to","I cannot concentrate at all"] | Concentration |
| Constipation, loose bowels, or diarrhea | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| COPD | ["yes","no"] | Chronic obstructive |
| Cough | ["yes","no"] | Do you frequently ex |
| Coughing up blood | ["yes","no"] | Coughing up blood/He |
| Dental Problems | ["yes","no"] | Dental problems incl |
| Depression | ["yes","no"] | A mental health diso |
| Diabetes | ["yes","no"] | A group of diseases |
| Did any doctor diagnose you with an allergic disease? | ["yes","no"] | AQUA©: Allergy Ques |
| Did you ever use anti-allergic drugs (antihistamines, topical steroids, "allergy vaccines")? | ["yes","no"] | AQUA©: Allergy Ques |
| Difficulty hearing | ["yes","no"] | Difficulty hearing |
| Dizziness | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Do heavy household chores (e.g., wash walls, floors). | ["No difficulty","Mild difficulty","Moderate difficulty","Severe difficulty","Unable"] | QucikDASH#2 |
| Do you frequently sneeze, have a runny, itchy nose, (apart from colds)? | ["yes","no"] | AQUA©: Allergy Ques |
| Do you have a problem accessing food | ["yes","no"] | n/a |
| Do you have any Pain? | ["yes","no"] | I want to know if yo |
| Do you suspect you suffer from allergy, independent from any medical diagnosis. ? | ["yes","no"] | AQUA©: Allergy Ques |
| Doctors are good about explaining the reason for medical tests. | ["Strongly Agree","Agree","Uncertain","Disagree","Strongly Disagree"] | PSQ-18 |
| Does pain, numbness, tingling or weakness extend into your leg (from the low back) and/or arm (from the neck)? | ["None of the Time - 0","1","2","3","4","5","6","7","8","9","All of the Time - 10"] | Does pain, numbness, |
| Does your health now limit you in doing eight hours of physical labor? | ["Not at all","Very Little","Somewhat","Quite a lot","Cannot do","a","b","c","d","e"] | Promis Global Health |
| Does your health now limit you in doing strenuous activities such as backpacking, skiing, playing tennis, bicycling or jogging? | ["Not at all","Very Little","Somewhat","Quite a lot","Cannot do","a","b","c","d","e"] | Promis Global Health |
| Does your health now limit you in doing two hours of physical labor? | ["Not at all","Very Little","Somewhat","Quite a lot","Cannot do","a","b","c","d","e"] | Promis Global Health |
| Driving | ["I can drive my car without any neck pain","I can drive my car as long as I want with slight pain in my neck","I can drive my car as long as I want with moderate pain in my neck","I can\u2019t drive my car as long as I want because of moderate pain in my neck","I can hardly drive at all because of severe pain in my neck","I can\u2019t drive my car at all"] | Driving |
| During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? | ["No difficulty","Mild difficulty","Moderate difficulty","Severe difficulty","Unable"] | QucikDASH #11 |
| During the past week, to what extent has your arm, shoulder, or hand problem interfered with your normal social activities with family, friends, neighbors? | ["Not at all","Slightly","Moderately","Quite a bit","Extremely"] | Quick DASH #7 |
| During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem. | ["Not limited at all","Slightly limited","Moderately limited","Very limited","Unable"] | Quick DASH #8 |
| Ears, Nose, Throat | ["yes","no"] | Ears, nose, throat |
| Elbow Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Employment/Homemaking | ["My normal homemaking\/ job activities do not cause pain.","My normal homemaking\/ job activities increase my pain, but I can still perform all that is required of me.","I can still perform all that is required of me.","I can perform most of my homemaking\/ job duties, but pain prevents me from performing more physically stressful activities (e.g. lifting, vacuuming)","Pain prevents me from doing anything but light duties.","Pain prevents me from performing any job or homemaking chores. "] | Oswestry Disability |
| Eyelid swelling | ["yes","no"] | Do you experience ey |
| Eyes/Vision | ["yes","no"] | Have you had any tro |
| Facial Pressure or Pain | ["yes","no"] | Do you experience fa |
| Fainting spells | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Feeling afraid as if something awful might happen | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Feeling bad about yourself or that you are a failure or have let yourself or your family down | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Feeling down, depressed, or hopeless | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Feeling nervous, anxious or on edge | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Feeling tired or having little energy | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Feeling tired or having low energy | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Feeling your heart pound or race | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Femoral Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Fever | ["yes","no"] | Fever, also referred |
| Fibromyalgia | ["yes","no"] | Fibromyalgia (FM) is |
| Finger Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Foot pain | ["yes","no"] | Foot pain |
| Foot Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| For how many years did you (have you) smoke(d) up to now? | ["Never","0-2 pack years","2-5 pack years","5-10 pack years","10-20 pack years","20 or more"] | For how many years d |
| Frequent Infections | ["yes","no"] | Frequent Infections |
| Get out of bed | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Getting into or out of a car. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #10 |
| Getting into or out of the bath. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #3 |
| Gluteal Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Going up or down 10 stairs (about 1 flight of stairs). | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #13 |
| Gout | ["yes","no"] | Gout is a form of in |
| Hair loss | ["yes","no"] | Hair loss |
| Hand Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Has there been a time in the past month when you have had serious thoughts about ending your life? | ["yes","no"] | Has there been a tim |
| Have you ever had an allergic reaction to foods? | ["yes","no"] | AQUA©: Allergy Ques |
| Have you ever, in your whole life, tried to kill yourself or made a suicide attempt? | ["yes","no"] | Have you ever, in yo |
| Head Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Head Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Headaches | ["I have no headaches at all","I have slight headaches, which come infrequently","I have moderate headaches, which come infrequently","I have moderate headaches, which come frequently","I have severe headaches, which come frequently","I have headaches almost all the time"] | NDI #5 I have no |
| Headaches | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Heart Attack | ["yes","no"] | A myocardial infarct |
| Heart Disease | ["yes","no"] | Disease involving th |
| Heart Failure | ["yes","no"] | Heart Failure |
| Heartburn | ["yes","no"] | Heartburn |
| Hepatitis | ["yes","no"] | Hepatitis is inflamm |
| High Blood Pressure | ["yes","no"] | High blood pressure |
| High Cholesterol | ["yes","no"] | It is a form of hype |
| Hip pain | ["yes","no"] | Hip pain |
| Hip Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| HIV/AIDS | ["yes","no"] | Human immunodeficien |
| Hoping. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #19 |
| How anxious (tense, uptight, irritable, fearful, difficulty in concentrating / relaxing) you have been feeling during the past week: | ["Not at all - 0","1","2","3","4","5","6","7","8","9","Extremely Anxious 10"] | How anxious (tense, |
| How much you have been able to control (reduce/help) your pain/ complaint on your own during the past week: | ["I can reduce it - 0","1","2","3","4","5","6","7","8","9","I can not reduce it at all - 10"] | How much you have be |
| How satisfied are you currently with your providers office? | ["1 - Not satisfied","2","3","4","5","6","7","8","9","10-Extremely satisfied"] | Clinic satisfaction |
| How satisfied are you with the level of care you are receiving by our providers and staff? | ["Very Satisfied","Somewhat Satisfied","Satisdied","Somewhat Dissatisified","Dissatisfied"] | Practice related |
| How successful have you been with following the recommendations of your health care provider for this past week? | ["1-Not successful","2","3","4","5","6","7","8","9","10-Extremely successful"] | Compliance |
| How would you rate your general health? | ["Poor - 0 ","1","2","3","4","5","6","7","8","9","Excellent - 10"] | How would you rate y |
| I can do light work for an hour. | ["Completely Agree - 0","1","2","3","4","5","6","7","8","9","Completely Disagree - 10"] | I can do light work |
| I can sleep at night. | ["Completely Agree - 0","1","2","3","4","5","6","7","8","9","Completely Disagree - 10"] | I can sleep at night |
| I feel confident that I can get the healthcare I need without being set back financially. | ["Strongly Agree","Agree","Uncertain","Disagree","Strongly Disagree"] | PSQ-18 #5 |
| I have had pain in the shoulder or neck at some time in the last 2 weeks | ["yes","no"] | STarTBack #2 |
| I have only walked short distances because of my back pain | ["yes","no"] | STarTBack #3 |
| I should not do my normal activities including work with my present pain. | ["Completely Disagree - 0","1","2","3","4","5","6","7","8","9","Completely Agree - 10"] | I should not do my n |
| I think my health care provider's office has everything needed to provide complete medical care. | ["Strongly Agree","Agree","Uncertain","Disagree","Strongly Disagree"] | PSQ-18 |
| If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people? | ["Not difficult at all. ","Somewhat difficult. ","Very difficult.","Extremely difficult. "] | If you are experienc |
| If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? | ["Not difficult at all. ","Somewhat difficult. ","Very difficult.","Extremely difficult. "] | If you checked off a |
| If you had to spend the rest of your life with your condition as it is right now, how would you feel about it? | ["Delighted - 0","1","2","3","4","5","6","7","8","9","Terrible - 10"] | If you had to spend |
| Impotence | ["yes","no"] | Impotence |
| In general I have not enjoyed all the things I used to enjoy | ["Agree","Disagree"] | STarTBack #8 |
| In general, would you say your health is: | ["Excellent","Very Good","Good","Fair","Poor"] | SF-36 |
| In the last 2 weeks, I have dressed more slowly than usual because of back pain | ["yes","no"] | STarTBack #4 |
| In the past 7 days - How often do you feel tired? | ["Never","Rarely","Sometimes","Often","Always"] | PROMIST Short Form 7 |
| In the past year, have you felt depressed or sad most days even if you felt okay sometimes? | ["yes","no"] | In the past year, ha |
| Inguinal Pain VAS Left/Right | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Intolerance to heat or cold | ["yes","no"] | Intolerance to heat |
| It's not really safe for a person with a condition like mine to be physically active | ["Agree","Disagree"] | STarTBack #5 |
| Itchy nose | ["yes","no"] | In the past week hav |
| Itchy/Watery Eyes | ["yes","no"] | Itchy/watery eyes ma |
| Kidney Disease | ["yes","no"] | Kidney disease, or r |
| Knee pain | ["yes","no"] | Knee pain |
| Knee Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Knee Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Lateral epicondyle Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Leg/Crural Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Leukemia | ["yes","no"] | Leukemia |
| Lift and carry a heavy suitcase | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Lifting | ["I can lift heavy weights without extra pain","I can lift heavy weights but it gives extra pain","Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table","Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned","I can only lift very light weights","I cannot lift or carry anything"] | NDI #3 I can li |
| Lifting | ["I can lift heavy weights without extra pain","I can lift heavy weights but it gives extra pain","Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table","Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned","I can lift very light weights","I cannot lift or carry anything at all"] | I can lift heavy wei |
| Lifting | ["I can lift heavy weights without extra pain.","I can lift heavy weights but it gives extra pain.","Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned, e.g. on a table.","Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned.","I can lift only very light weights.","I cannot lift or carry anything at all."] | Section 3 - Lifting< |
| Lifting an object, like a bag of groceries from the floor. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #7 |
| Little interest or pleasure in doing things | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Liver Disease | ["yes","no"] | Liver disease (also |
| Lower Back Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Lower Back Pain VAS Left/Right | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Lungs, breathing | ["yes","no"] | Lungs, breathing |
| Make your bed | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Making sharp turns while running fast. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #18 |
| Medial epicondyle Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Menstrual cramps or other problems with your periods (Women Only) | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Move a chair | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around a lot more than usual. | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| MRSA Infections | ["yes","no"] | Methicillin-resistan |
| My back pain has spread down my leg(s) at some time in the last 2 weeks | ["yes","no"] | STarTBack #1 |
| Nausea, gas, or indigestion | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Neck Pain | ["yes","no"] | General questions |
| Neck Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Neck Pain VAS Left/Right | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Not being able to stop or control worrying | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| On a scale of 0 to 10, how certain are you that you will be doing normal activities or working in six months? | ["Very Certain - 0 ","1","2","3","4","5","6","7","8","9","Not Certain at All - 10"] | On a scale of 0 to 1 |
| Open a tight or new jar. | ["No difficulty","Mild difficulty","Moderate difficulty","Severe difficulty","Unable"] | QucikDASH#1 |
| Osteoarthritis | ["yes","no"] | Osteoarthritis (OA) |
| Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing)have you been feeling? | ["Not at all anxious - 0","1","2","3","4","5","6","7","8","9","Extremely anxious - 10"] | Bournemouth #4 |
| Over the past week, how depressed(down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling? | ["Not at all depressed -0","1","2","3","4","5","6","7","8","9","Extremely depressed - 10"] | Bournemouth #5 |
| Over the past week, how have you felt work (both inside and outside the home) has affected (or would affect) your back pain? | ["Have made it no worse -0","1","2","3","4","5","6","7","8","9","Have made it much worse - 10"] | Bournemouth #6 |
| Over the past week, how much has your back pain interfered with your ability to take part in recreational, social, and family activities? | ["No interference - 0","1","2","3","4","5","6","7","8","9","Unable to carry out activity -10"] | Bournemouth #3 |
| 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)? | ["No interference - 0","1","2","3","4","5","6","7","8","9","Unable to carry out activity -10"] | Bournemouth #2 |
| Over the past week, how much have you been able to control (reduce/help) your back pain on your own? | ["Completely control it -0","1","2","3","4","5","6","7","8","9","No control whatsoever - 10"] | Bournemouth #7 |
| Over the past week, on average, how would you rate your back pain? | ["No pain - 0","1","2","3","4","5","6","7","8","9","Worst pain possible - 10"] | Bournemouth #1 |
| Overall, how bothersome has your back pain been in the last 2 weeks? | ["Not at all","Slightly","Moderately","Very much","Extremely"] | STarT Back #9 |
| Pain in legs with walking | ["yes","no"] | Pain in legs with wa |
| Pain in your arms, legs, or joints (knees, hips, etc) | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Pain Intensity | ["I have no pain at the moment.","The pain is very mild at the moment.","The pain comes and goes and is moderate.","The pain is fairly severe at the moment.","The pain is very severe at the moment.","The pain is the worst imaginable at the moment."] | |
| Pain Intensity | ["I can tolerate the pain I have without having to use pain killers","The pain is bad but I manage without taking pain killers","Pain killers give complete relief from pain","Pain killers give moderate relief from pain ","Pain killers give very little relief from pain ","Pain killers have no effect on the pain and I do not use them"] | Oswestry Disability |
| Pain intensity | ["I have no pain at the moment.","The pain is very mild at the moment.","The pain is moderate at the moment.","The pain is fairly severe at the moment.","The pain is very severe at the moment.","The pain is the worst imaginable at the moment."] | Oswestry Disability |
| Pain or problems during sexual intercourse | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Pain/stiffness during the day How severe was your usual joint or muscle pain and/or stiffness overall during the day in the last 2 weeks? | ["Not at all","Slightly","Moderately","Fairly severe","Very severe"] | Pain/stiffness durin |
| Painful urination | ["yes","no"] | Painful urination/Dy |
| Palm Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Performing heavy activities around your home. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #9 |
| Performing light activities around your home. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #8 |
| Peroneal Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Personal Care (Washing, Dressing, etc.) | [" I can look after myself normally without causing extra pain","I can look after myself normally but it causes extra pain","It is painful to look after myself and I am slow and careful","I need some help but can manage most of my personal care"," I need help every day in most aspects of self care"," I do not get dressed, I wash with difficulty and stay in bed"] | NDI #2 I can l |
| Personal Care (Washing, Dressing, etc.) | [" I can look after myself normally without causing extra pain","I can look after myself normally but it causes extra pain","It is painful to look after myself and I am slow and careful","I need some help but can manage most of my personal care"," I need help every day in most aspects of self care"," I do not get dressed, I wash with difficulty and stay in bed"] | ODI I can loo |
| Personal care (washing, dressing, etc.) | ["I can look after myself normally without causing extra pain.","I can look after myself normally but it is very painful.","It is painful to look after myself and I am slow and careful.","I need some help but manage most of my personal care.","I need help every day in most aspects of self care.","I do not get dressed, wash with difficulty and stay in bed."] | Section 2 - Personal |
| Personal care (washing, dressing, etc.) | ["I can look after myself normally without causing extra pain.","I can look after myself normally but it is very painful.","It is painful to look after myself and I am slow and careful.","I need some help but manage most of my personal care.","I need help every day in most aspects of self care.","I do not get dressed, wash with difficulty and stay in bed."] | Section 2 - Personal |
| Physical activity makes my pain worse. | ["Completely Disagree - 0","1","2","3","4","5","6","7","8","9","Completely Agree - 10"] | Physical activity ma |
| Please indicate how depressed (eg. Down-in-the-dumps, sad, downhearted, in low spirits, pessimistic, feelings of hopelessness) you have been feeling in the past week: | ["Not Depressed at All - 0","1","2","3","4","5","6","7","8","9","Extremely Depressed - 10"] | Please indicate how |
| Please indicate your usual level of pain during the past week: | ["No Pain - 0","1","2","3","4","5","6","7","8","9","Worst Possible Pain - 10"] | Please indicate your |
| Pneumonia | ["yes","no"] | Pneumonia is an infl |
| Poor appetite or overeating | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Popliteal Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Problems with walking or balance | ["yes","no"] | Problems with walkin |
| Prostate problems | ["yes","no"] | Prostate problems |
| Pubic Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Pull or push heavy doors | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Pulmonary Embolism | ["yes","no"] | Pulmonary embolism i |
| Put on socks (pantyhose) | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Putting on your shoes or socks. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #5 |
| Reach up to high shelves | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Reading | [" I can read as much as I want to with no pain in my neck","I can read as much as I want to with slight pain in my neck","I can read as much as I want with moderate pain in my neck","I can\u2019t read as much as I want because of moderate pain in my neck","I can hardly read at all because of severe pain in my neck","I cannot read at all"] | NDI #9 I can read |
| Recreation | ["I am able to engage in all my recreation activities with no neck pain at all","I am able to engage in all my recreation activities, with some pain in my neck","I am able to engage in most, but not all of my usual recreation activities because of pain in my neck","I am able to engage in a few of my usual recreation activities because of pain in my neck","I can hardly do any recreation activities because of pain in my neck","I can\u2019t do any recreation activities at all"] | Recreation |
| Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.). | ["No difficulty","Mild difficulty","Moderate difficulty","Severe difficulty","Unable"] | QucikDASH #6 |
| Rheumatoid Arthritis | ["yes","no"] | Rheumatoid arthritis |
| Ride in a car | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Ringing in ear | ["yes","no"] | Tinnitus/Ringing in |
| Rolling over in bed. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #20 |
| Run one block (about 100m) | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Running nose | ["yes","no"] | In the past week, ha |
| Running on even ground. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #16 |
| Running on uneven ground. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #17 |
| Runny nose | ["No","Yes - clear","Yes - cloudy"] | Have you had a runny |
| Seasonal Allergies | ["yes","no"] | Seasonal Allergies |
| Seizures | ["yes","no"] | A seizure, formally |
| Sex life (if applicable) | ["My sex life is normal and causes no extra pain.","My sex life is normal but causes some extra pain.","My sex life is nearly normal but is very painful.","My sex life is severely restricted by pain.","My sex life is nearly absent because of pain.","Pain prevents any sex life at all."] | Section 8 - Sex life |
| Shortness of breath | ["No","Yes"] | Shortness of breath |
| Shortness of breath | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Shoulder pain | ["yes","no"] | Shoulder pain |
| Shoulder Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Sit in a chair for several hours | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Sitting | ["I can sit in any chair as long as I like","I can only sit in my favorite chair as long as I like","Pain prevents me from sitting more than one hour","Pain prevents me from sitting more than \u00bd hour","Pain prevents me from sitting more than 10 minutes","Pain prevents me from sitting at all "] | Oswestry Disability |
| Sitting | ["I can sit in any chair as long as I like.","I can sit in my favourite chair as long as I like.","Pain prevents me from sitting for more than 1 hour.","Pain prevents me from sitting for more than 1\/2 an hour.","Pain prevents me from sitting for more than 10 minutes.","Pain prevents me from sitting at all."] | Section 5 - Sitting< |
| Sitting for 1 hour. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #15 |
| Skin Problems | ["yes","no"] | Skin problems. |
| Sleep through the night | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Sleeping | ["I have no trouble sleeping.", "My sleep is slightly disturbed","My sleep is slightly disturbed (less than 1 hour sleepless).","My sleep is mildly disturbed (1-2 hours sleepless).","My sleep is moderately disturbed (2-3 hours sleepless).","My sleep is greatly disturbed."] | NDI #7 |
| Sleeping | ["Pain does not prevent me from sleeping well","I can sleep well only by using medication","Even when I take medication, I have less than 6 hrs sleep","Even when I take medication, I have less than 4 hrs sleep","Even when I take medication, I have less than 2 hrs sleep","Pain prevents me from sleeping at all "] | Oswestry Disability |
| Sleeping | ["My sleep is never disturbed by pain.","My sleep is occasionally disturbed by pain.","Because of pain I have less than 6 hours sleep.Because of pain I have less than 6 hours sleep.","Because of pain I have less than 4 hours sleep.","Because of pain I have less than 2 hours sleep.","Pain prevents me from sleeping at all."] | Section 7 - Sleeping |
| Social Life | ["My social life is normal and gives me no extra pain","My social life is normal but increases the degree of pain","Pain has no significant effect on my social life apart from limiting my more energetic interests, i.e. dancing, etc.","Pain has restricted my social life and I do not go out as often","Pain has restricted my social life to my home","I have no social life because of pain"] | Oswestry Disability |
| Social life | ["My social life is normal and causes me no extra pain.","My social life is normal but increases the degree of pain.","Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. sport, etc.","Pain has restricted my social life and I do not go out as often.","Pain has restricted social life to my home.","I have no social life because of pain."] | Section 9 - Social l |
| Sometimes healthcare providers make me wonderif their diagnosis is correct. | ["Strongly Agree","Agree","Uncertain","Disagree","Strongly Disagree"] | PSQ-18 #4 |
| Sore throat | ["yes","no"] | Sore throat/Pharyngi |
| Squatting. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #6 |
| Stand up for 20-30 minutes | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Standing | ["I can stand as long as I want without extra pain","I can stand as long as I want but it gives me extra pain","Pain prevents me from standing for more than one hour","Pain prevents me from standing for more than 30 minutes","Pain prevents me from standing for more than 10 minutes","Pain prevents me from standing at all "] | Oswestry Disability |
| Standing | ["I can stand as long as I want without extra pain.","I can stand as long as I want but it gives me extra pain.","Pain prevents me from standing for more than 1 hour.","Pain prevents me from standing for more than 1\/2 an hour.","Pain prevents me from standing for more than 10 minutes.","Pain prevents me from standing at all."] | Section 6 - Standing |
| Standing for 1 hour. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #14 |
| Stomach Disease | ["yes","no"] | Stomach diseases inc |
| Stomach pain | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Stroke | ["yes","no"] | A stroke is a medica |
| Suboccipital Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Suboccipital Pain VAS Left/Right | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Sural/Calf Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Swelling of feet or legs | ["yes","no"] | Swelling of feet or |
| Take food out of the refrigerator | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Teeth/Mouth problems | ["yes","no"] | Teeth, mouth |
| test axial cs circ | ["yes","no"] | test |
| test multiregion Everything good? | ["yes","no"] | test |
| The health care I have been receiving is just about perfect. | ["Strongly Agree","Agree","Uncertain","Disagree","Strongly Disagree"] | PSQ-18 |
| Thenar Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Thoracic Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Thoracic Pain VAS Left/Right | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Thoughts that you would be better off dead or of hurting yourself in some way. | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Throw a ball | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Toe Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| Traveling | ["I can travel anywhere without extra pain","I can travel anywhere but it gives me extra pain","Pain is bad, but I manage journeys over 2 hours","Pain restricts me to journeys of less than 1 hour","Pain restricts me to short necessary journeys under 30 minutes","Pain prevents me from traveling except to the doctor or hospital "] | Oswestry Disability |
| Traveling | ["I can travel anywhere without pain.","I can travel anywhere but it gives extra pain.","Pain is bad but I manage journeys over two hours.","Pain restricts me to journeys of less than one hour.","Pain restricts me to short necessary journeys under 30 minutes.","Pain prevents me from travelling except to receive treatment."] | Section 10 - Travell |
| Trouble concentrating on things like school work, reading, or watching television? | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Trouble concentrating on things, such as reading the newspaper or watching television. | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Trouble falling/staying asleep, sleeping too much | ["Not at all","Several days","More than half the days","Nearly every day"] | Trouble falling/stay |
| Trouble relaxing | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Trouble sleeping | ["Not bothered at all","Bothered a little","Bothered a lot"] | PHQ-15 Physical Symp |
| Turn over in bed | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Use a knife to cut food. | ["No difficulty","Mild difficulty","Moderate difficulty","Severe difficulty","Unable"] | QucikDASH #5 |
| Walk a few blocks (300-400m) | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Walk several kilometers | ["Not difficult at all","Minimally difficult","Somewhat difficult","Fairly difficult","Very difficult","Unable to do"] | The Quebec Back Pain |
| Walking | ["Pain does not prevent me walking any distance","Pain prevents me walking more than one mile","Pain prevents me walking more than \u00bd mile","Pain prevents me walking more than \u00bc mile","I can only walk using a stick or crutches","I am in bed most of the time and have to crawl to the toilet "] | Oswestry: Pai |
| Walking | ["Pain does not prevent me walking any distance.","Pain prevents me walking more than 1 mile.","Pain prevents me walking more than than 1\/2 of a mile.","Pain prevents me walking more than 100 yards.","I can only walk using a stick or crutches.","I am in bed most of the time and have to crawl to the toilet."] | Section 4 - Walking< |
| Walking 2 blocks. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #11 |
| Walking a mile. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #12 |
| Walking between rooms. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #4 |
| Wash your back. | ["No difficulty","Mild difficulty","Moderate difficulty","Severe difficulty","Unable"] | QucikDASH #4 |
| Weakness | ["yes","no"] | Weakness |
| Weight Loss | ["yes","no"] | Weight loss, in the |
| What has been the severity of the tingling in your arm, shoulder or hand? | ["None","Mild","Moderate","Severe","Extreme"] | Quick DASH #10 |
| What has been the severity of the your arm, shoulder or hand pain? | ["None","Mild","Moderate","Severe","Extreme"] | Quick DASH #9 |
| What is your favorite color? | ["red","blue"] | I loke colors |
| Work | ["I can do as much work as I want to","I can only do my usual work, but no more","I can do most of my usual work, but no more","I cannot do my usual work","I can hardly do any work at all","I can\u2019t do any work at all"] | NDI #7 Work |
| Worrying thoughts have been going through my mind a lot of the time | ["Agree","Disagree"] | STarTBack #6 |
| Worrying too much about different things | ["Not at all","Several days","More than half the days","Nearly every day"] | Over the last 2 week |
| Wrist pain | ["yes","no"] | Wrist pain |
| Wrist Pain VAS | ["0 - No pain","1","2","3","4","5","6","7","8","9","10 - Worst pain"] | This question repres |
| y | ["Yes","No"] | y |
| Your usual hobbies, recreational or sporting activities. | ["Extreme Difficulty","Quite a bit of difficulty","Moderate difficulty","A little bit of difficulty","No difficulty"] | LEFS #2 |