Questionnaires Back Pain Questionnaire Dr. Idema Back Pain Name Name * First Name Last * Last Name Email * Extent to which function is affected Sleeping 0 Walking 0 Sitting 0 Standing 0 Exercising 0 Traveling 0 Family Time 0 Working 0 Romance 0 Social Life 0 When did you first notice your low back pain? * What conservative treatment measures have you used to attempt to control your low back pain? * Physical Therapy Injections STIM Water Therapy Chiropractor Bracing Pain MedicationPain Medication OtherOther How long have you been using these conservative treatment measures for? * 0-3 Months 3-6 Months 6-9 Months 9+ Months Have you missed work due to your low back pain? * Yes No Submit If you are human, leave this field blank.