Please fill out the following questions about your upper and lower back from the past month. Tick the most appropriate answer for each question. If you wear a brace, answer the questions for the times when you were not wearing the brace. |
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1. To what extent do you feel pain in your upper or lower back while lying down? â–¡Not at all â–¡Mild â–¡Moderate â–¡Considerable â–¡Severe |
2. To what extent do you feel pain in your upper or lower back after sitting for an hour? â–¡Not at all â–¡Mild â–¡Moderate â–¡Considerable â–¡Severe |
3. To what extent do you feel pain in your upper or lower back after standing for long periods? â–¡Not at all â–¡Mild â–¡Moderate â–¡Considerable â–¡Severe |
4. To what extent do you feel stiffness or soreness in your shoulders or neck? â–¡Not at all â–¡Mild â–¡Moderate â–¡Considerable â–¡Severe |
5. To what extent do you feel uncomfortable when wearing a jacket or coat? â–¡Not at all â–¡Mild â–¡Moderate â–¡Considerable â–¡Severe |
6. To what extent are you concerned about the waistline of a skirt? â–¡Not at all â–¡Mild â–¡Moderate â–¡Considerable â–¡Severe |
7. To what extent do you have difficulty putting on socks or stockings? â–¡Not at all â–¡Mild â–¡Moderate â–¡Considerable â–¡Severe |
8. To what extent are you concerned about the fit of T-shirts? â–¡Not at all â–¡Mild â–¡Moderate â–¡Considerable â–¡Severe |
9. To what extent are you bothered by the slipping of bra or camisole straps from your shoulders? â–¡Not at all â–¡Mild â–¡Moderate â–¡Considerable â–¡Severe |
10. To what extent are you self-conscious about the curve of your back when wearing lighter clothing in warmer weather? â–¡Not at all â–¡Slightly â–¡Moderately â–¡Strongly â–¡Extremely |
11. Do you find yourself wanting to avoid exercise? â–¡Not at all â–¡Slightly â–¡Moderately â–¡Strongly â–¡Extremely |
12. Have parents, friends, or teachers told you that you have a back problem? â–¡Never â–¡Rarely â–¡Sometimes â–¡Often â–¡Very often |
13. Do you feel embarrassed to bathe with your mother or sisters because of the curve of your back? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
14. How self-conscious are you about classmates or colleagues noticing your appearance? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
15. Do you become anxious when standing in front of a group of people? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
16. To what extent are you reluctant to participate in sporting events or performances? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
17. To what extent does your appearance in the mirror make you self-conscious? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
18. To what extent are you self-conscious about the x-ray images on your back? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
19. Do you feel sports or exercise will have a negative effect on your spine? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
20. Do you worry about your future regarding marriage, childbirth, and your children inheriting your condition? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
21. To what extent do you wish you could change the current condition of your spine? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
22. To what extent do you feel shy or reclusive because of the shape of your spine? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
23. To what extent do you feel depressed due to the condition of your spine? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
24. To what extent do you feel an inferiority complex due to the shape of your spine? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
25. To what extent do you feel overly self-conscious about your appearance due to the shape of your spine? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
26. To what extent do you think of yourself as less capable than others because of your spine? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |
27. To what extent do you feel self-conscious about how you hold bags? â–¡Not at all â–¡Slightly â–¡Somewhat â–¡Quite â–¡Very much |