My Back Pain: Check List
I have had pain since _________ Weeks ___________ Months
Since then it has gotten __better ___ worse (Please X the appropriate blank)
My pain starts:
| __suddenly | __sneaking up on me |
| __without cause | __in certain positions |
| __at any time | __at certain times |
| __with certain motions | __when resting |
| __frequently | __occasionally |
| __constantly present |
The pain is:
| __of short duration | __long lasting |
| __constant | __grows in intensity |
| __location specific | __radiating |
| __always equally strong | __varing |
The pain feels:
| __sharp | __dull |
| __like burning | __pressing |
| __like stabbing | __blistering |
| __pulsating | __pins and needles |
