Low Back Pain Screening Questionnaire

When did your episode of lower back pain start *

Does your lower back pain move and/or you experience your pain in multiple places? *

Yes

No

Do you suffer with any pain down the back of your thigh or leg? *

Yes

No

Do you experience any odd sensations such as pins and needles or numbness? *

Yes

No

Are you experiencing any muscle weakness? Such as not being able to stand on one leg or a loss of power on walking? *

Yes

No

Have you noticed any loss of muscle tone and/or size in your legs since the onset of your lower back pain? *

Yes

No

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