New zealand acute low back pain guide

New Zealand Acute Low Back Pain Guide
Patient Information

Screening Questionnaire
(Linton & Halldén 1996)

These questions and statements apply if you have aches or pains, such as back, shoulder or neck pain. Please read and answer each question carefully. Do not take too long to answer the questions. However, it is important that you answer every question. There is always a response for your particular situation.

1. What year were you born?: 19____
2. Are you:
 male  female
3. Were you born in New Zealand?
 yes  no
4. Where do you have pain? Place a tick ( ) for all the appropriate sites.
 neck  shoulders  upper back  lower back  leg
5. How many days of work have you missed because of pain during the past 18 months? Tick ( ) one.
 0 days [1]  1-2 days [2]  3-7 days [3]  8-14 days [4]  15-30 days [5]
 1 month [6]  2 months [7]  3-6 months [8]  6-12 months [9]  over 1 year [10]
6. How long have you had your current pain problem? Tick ( ) one.
 0-1 weeks [1]  1-2 weeks [2]  3-4 weeks [3]  4-5 weeks [4]  6-8 weeks [5]
 9-11 weeks [6]  3-6 months [7]  6-9 months [8]  9-12 months [9]  over 1 year [10]
7. Is your work heavy or monotonous? Circle the best alternative.
0 1 2 3 4 5 6 7 8 9 10
Not at all Extremely
8. How would you rate the pain that you have had during the past week? Circle one.
0 1 2 3 4 5 6 7 8 9 10
No pain Pain as bad
as it could be
9. In the past three months, on average, how bad was your pain? Circle one.
0 1 2 3 4 5 6 7 8 9 10
No pain Pain as bad
as it could be
10. How often would you say that you have experienced pain episodes, on average, during the past 3 months? Circle one.
0 1 2 3 4 5 6 7 8 9 10
Never Always
11. Based on all the things you do to cope, or deal with your pain, on an average day, how much are you able to decrease it? Circle one.
0 1 2 3 4 5 6 7 8 9 10
Can't decrease it at all Can decrease
it completely
12. How tense or anxious have you felt in the past week? Circle one.
0 1 2 3 4 5 6 7 8 9 10
Absolutely calm
and relaxed		 As tense and
anxious as I've ever felt
13. How much have you been bothered by feeling depressed in the past week? Circle one.
0 1 2 3 4 5 6 7 8 9 10
Not at all Extremely
14. In your view, how large is the risk that your current pain may become persistent? Circle one.
0 1 2 3 4 5 6 7 8 9 10
No risk Very large risk
15. In your estimation, what are the chances that you will be working in 6 months? Circle one.
0 1 2 3 4 5 6 7 8 9 10
No chance Very large chance
16. If you take into consideration your work routines, management, salary, promotion possibilities and work mates, how satisfied are you with your job? Circle one.
0 1 2 3 4 5 6 7 8 9 10
Not at all satisfied Completely
satisfied
Here are some of the things which other people have told us about their back pain. For each statement please circle one number from 0 to 10 to say how much physical activities, such as bending, lifting, walking or driving would affect your back. 17. Physical activity makes my pain worse
0 1 2 3 4 5 6 7 8 9 10
Completely disagree Completely
agree
18. An increase in pain is an indication that I should stop what I am doing until the pain decreases.
0 1 2 3 4 5 6 7 8 9 10
Completely disagree Completely
agree
19. I should not do my normal work with my present pain.
0 1 2 3 4 5 6 7 8 9 10
Completely disagree Completely
agree
Here is a list of 5 activities. Please circle the one number which best describes your current ability to participate in each of these activities. 20. I can do light work for an hour.
0 1 2 3 4 5 6 7 8 9 10
Can't do it because of pain problem Can do
it without pain
being a problem
21. I can walk for an hour.
0 1 2 3 4 5 6 7 8 9 10
Can't do it because of pain problem Can do
it without pain
being a problem
22. I can do ordinary household chores.
0 1 2 3 4 5 6 7 8 9 10
Can't do it because of pain problem Can do
it without pain
being a problem
23. I can go shopping.
0 1 2 3 4 5 6 7 8 9 10
Can't do it because of pain problem Can do
it without pain
being a problem
24. I can sleep at night.
0 1 2 3 4 5 6 7 8 9 10
Can't do it because of pain problem Can do
it without pain
being a problem