Quiz – Safety Screen - ThePainFreeBack

Are you 16 years of age or older?

I am 16 or older.

I am younger than 16.

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Are you Pregnant?

No I am not.

Yes I know I am currently pregnant, or there is a high probability that I am.

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Is your back pain accompanied by vaginal bleeding, fever, or burning during urination?

No it is not

Yes it is.

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Have you had any sort of surgery within the last year?

No, I have not.

Yes, I have.

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Did your surgeon tell you to avoid any sort of physical activity or movement?

No, they did not.

Yes, I was told to avoid certain motions or activites.

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Have you been cleared of these restrictions either by confirmation from your surgeon or by the passing of a pre-determined timeline?

No, these restrictions are stil applicable.

Yes, I know longer have to follow the restrictions.

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Did your back pain start around the same time as a fever?

No, there was not a fever associated with my back pain.

Yes, my back pain developed around the same time as a fever.

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Do you have ANY of the following:

Unexplained weight loss.

Painful or difficult urination.

An unhealing wound.

Neurological deficits such as weakness and/or numbness of both arms or legs, incontinence of bowels, and/or bladder.

No, none of these statements apply to me.

Yes, one or more of these statements apply to me.

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In the last year, did you experience a significant fall, car accident, or another injury?

No, nothing significant comes to mind.

Yes, there was a fall, injury, or accident.

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Have you had a spinal X-ray to rule out a fracture?

I have not had an X-ray or one has shown I have an unhealed fracture.

Yes, I had an X-ray and there were no signs of fracture.

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Has your pain been severe since the time of your injury and does it get even worse with transitional movements such as going from laying down to sitting?

No, the pain has gotten better and those types of movements don’t bother me more than others.

Yes, the pain is unbearable, and hurts even more with those types of movement.

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Are you over 70 years old or have been diagnosed with osteoporosis?

No, I am younger than 70 OR do not have osteoporosis.

Yes, I am older than 70 OR have osteoporosis.

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Do you have a history of Cancer?

No, I do not currently have cancer and I have never had cancer.

Yes, I currently have cancer or have had cancer in the past.

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Do TWO or MORE of the following apply to you?

Back pain that doesn’t seem to be related to movement or doesn’t get worse with movement.

Back pain that usually occurs at night or early in the morning and goes away or gets better during the day.

Changes in your bowel habits, such as blood in your urine or stool or a decreased ability to pee.

Sudden, unexplained weight loss.

Weakness, tingling, or numbness in both your arms or legs.

No, less than two, or none, of these apply to me.

Yes, two or more of these apply to me.

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Do THREE or MORE of the following apply to you?

Back pain that doesn’t seem to be related to movement or doesn’t get worse with movement.

Back pain that usually occurs at night or early in the morning and goes away or gets better during the day.

Changes in your bowel habits, such as blood in your urine or stool or a decreased ability to pee.

Sudden, unexplained weight loss.

Weakness, tingling, or numbness in both of your arms or legs.

No, less than three, or none, of these apply to me.

Yes, three or more of these apply to me.

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