If you are visiting your Primary Care Physician about back pain, make sure your visit covers as many possibilities as you can. Filling out this form in advance and taking it with you will help;
Allergies: _________________________ Medications currently taking: __________________________________________________________________
Are you pregnant? When was your last period?
When did the pain start- (acute <6 weeks chronic > 3 months acute on chronic etc.
Injury/trauma/overuse twisting lifting bending etc.
Have you had this kind of pain before-
If you have, is there anything different about this pain-
Describe the severity of the discomfort on a scale of 1-10 10 being the worst pain imaginable, how bad is it at its;
How long does it usually stay at the different levels etc;
What does it feel like- quality – sharp or dull, burning, ache, stabbing, cramping/spasms, shock like etc –
Where is the pain area / size of pain- Draw a picture and put “x”s where it hurts and “o”s where it might radiate
Does the pain move around or radiate anywhere or stay in one area-
Is it only in the center? Across the back? Down one leg R or L ? or both and how far down the leg does it go?
Change as time progresses since started- getting better worse or the same
Timing issues that affect pain-
Menses or part of cycle- no association
Having bowel movement or bearing down- when was your last BM?
Taking a deep breath
Standing, walking or bouncing/ hopping
Does it hurt when you push on the area where you are feeling discomfort?
Things that make better- positions or activities
Things that make it worse- moving in certain positions etc.
Any weakness in your legs, feet or ankles?
Back pain triage questions page 2
Does your foot slap or flop when you walk?
Associated other signs or symptoms?
Fever chills night sweats weight loss fatigue nausea vomiting diarrhea
Black or bloody stool
Does it wake you from sleep?
Does it keep you awake like a “nagging can’t get comfortable toothache”?
Any bloody or discolored urine?
Any “saddle numbness” in the crotch groin inner thighs?
Pulsatile/heart beat pulsing or tearing nature of the pain?
What if anything have you taken for the pain so far-
Have you recently been taking regular NSAID medications like Advil (Ibuprofen), Aleve (naproxen), aspirin or Rx meds for arthritis or Prednisone/Medrol steroids?
If so what and how many (dose in mg. etc.) and how often are you taking them?
Recent (last 2-3 months) antibiotics or infection like pneumonia urinary tract infection
Previous tests to evaluate pain- Cat Scans, Ultrasounds, Colonoscopy or upper endoscopy Upper or Lower GI tests etc.
What things can you not do now that affect your life due to the pain?
(Could you go to the market and pickup a gallon of milk without needing a shopping cart? Etc.)