Illumination Rock Integrative Medicine

Name *

First Name

Last Name

My back pain has spread down my leg(s) at some time in the last 2 weeks *

Disagree

Agree

I have had pain in the shoulder or neck at some time in the last 2 weeks *

Disagree

Agree

I have only walked short distances because of my back pain *

Disagree

Agree

In the last 2 weeks, I have dressed more slowly than usual because of back pain *

Disagree

Agree

It's not really safe for a person with a condition like mine to be physically active *

Disagree

Agree

Worrying thoughts have been going through my mind a lot of the time *

Disagree

Agree

I feel that my back pain is terrible and its never going to get any better *

Disagree

Agree

In general I have not enjoyed all the things I used to enjoy *

Disagree

Agree

Overall, how bothersome has your back pain been in the last 2 weeks? *

Not at all

Slightly

Moderately

Very much

Extremely