EFTA00313724.pdf

• V a ./1.0 I 1.4 • Women's Sports Medicine Center PLEASE FILL OUT THE FOLLOWING SECTION IF YOU ARE EXPERIENCING BACK PAIN Jeffrey Epstein July 6.2016 Patient Name: Date: Please read instructions: When your back and/or legs hurt, you may find it difficult to do some of the things you normally do. Mark only the sentences that describe you today. I stay at home most of the time because of my back and/or leg pain. I change position frequently to try to get my back and/or legs comfortable. I walk more slowly than usual because of my back and/or leg pain. Because of my back and/or leg pain, I am not doing any jobs that I usually do around the house. Because of my back and/or leg pain, I use a handrail to get upstairs. Because of my back and/or leg pain, I lie down to rest more often. Because of my back and/or leg pain. I have to hold on to something to get out of an easy chair. Because of my back and/or leg pain, I try to get other people to do things for me. I get dressed mole slowly than usual because of my back and/or leg pain. I only stand up for short periods of time because of my back and/or leg pain Because of my back and/or leg pain, I try not to bend or kneel down. I find it difficult to get out of a chair because of my back and/or leg pain. My back and/or legs are painful almost all of the time. 1 fund it difficult to turn over in bed because of my back and/or leg pain. My appetite is not very good because of my back and/or leg pain. ❑ I have trouble putting on my sock (or stockings) because of the pain in mw I can only walk short distances because of my back and/or leg pain. I sleep less well because of my back and/or leg pain. Because of my back and/or leg pain, I get dressed with the help of someone else. I sit down for most of the day because of my back and/or leg pain. I avoid heavy jobs around the house because of my back and/or leg pain. Because of back and/or leg pain, I am more irritable and bad tempered with people than usual. Because ofmy back and/or leg pain, I go upstairs more slowly than usual. I stay in bed most of the time because of my back and/or leg pain. TO BE FILLED OUT BY PHYSICIAN Score: Temp: BP: Pulse: Respirations: Weight Height EFTA00313724