Back Pain Review

If you have been advised by the surgery to submit a back pain review, please complete this form.

Back Screening Tool

Patient Details

Please use this date format: DD/MM/YYYY.

Back Screening Questionnaire

My back pain has spread down my leg(s) at some time in the last 2 weeks.
I have had pain in the shoulder or neck at some time in the last 2 weeks.
I have only walked short distances because of back pain in the last 2 weeks.
I have dressed more slowly than usual because of back pain in the last 2 weeks.
It's not really safe for a person with a condition like mine to be physically active.
Worrying thoughts have been going through my mind a lot of the time.
I feel that my back pain is terrible and it's never going to get any better.
In general I have not enjoyed all the things I used to enjoy.
Overall, how bothersome has your back pain been in the last 2 weeks?
When you are happy with all of the above answers, please click 'Submit' below and the questionnaire will automatically be sent to us. Depending upon your answers and your other medical conditions, you will be informed that either you do or do not need to be seen in clinic for a further assessment. If you have not heard anything after 2 weeks, please contact us directly.