I am now going to ask you a series of questions about the effects that [INSERT TREATMENT MODALITY] may have on your back pain and how back pain impacts your life. In each case, the question is asking about the results at the end of the treatment period. |
1. | How much change do you hope for in your back pain? Please answer on a scale of 0 to 10, where 0 is “no change or worse” and 10 is “complete relief.” |
| 0 1 2 3 4 5 6 7 8 9 10 |
| No Change/Worse Complete Relief |
2. | How much change do you realistically expect in your back pain? Please answer on a scale of 0 to 10, where 0 is “no change or worse” and 10 is “complete relief.” |
| 0 1 2 3 4 5 6 7 8 9 10 |
| No Change/Worse Complete Relief |
3. | How much change do you realistically expect in the impact of back pain on your life? Please answer on a scale of 0 to 10, where 0 is “no change or worse”, and 10 is “pain no longer impacts my life.” |
| 0 1 2 3 4 5 6 7 8 9 10 |
| No Change/Worse Back Pain No Longer Impacts My Life |
4. | How much change do you realistically expect in the impact of back pain on your daily activities? Please answer on a scale of 0 to 10, where 0 is “no change or worse” and 10 is “back pain no longer impacts my daily activities.” Or you may choose “not applicable” if back pain does not impact your daily activities now. |
| 0 1 2 3 4 5 6 7 8 9 10 |
| No Change /Worse Back Pain No Longer Impacts My Daily Activities |
| □ Not Applicable |