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Pain Questionnaire: Low Back Mobile App

When your back hurts, you may find it difficult to do some of the things you normally do. Use the Pain Questionnaire: Low Back mobile app to inform your medical provider of symptoms you are experiencing. Security and privacy are one of our core concerns at GoCanvas and we have equipped our product with the necessary features and capabilities to ensure that the data you capture is secure.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Pain Questionnaire: Low Back Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Patient's Name

  • Ico textbox

    Number

  • Ico date

    Date

  • Ico checkbox

    I can tolerate the pain without having to use painkillers.

  • Ico checkbox

    The pain is bad but I can manage without taking painkillers.

  • Ico checkbox

    Painkillers give complete relief from pain.

  • Ico checkbox

    Painkillers give moderate relief from pain.

  • Ico checkbox

    Painkillers give very little relief from pain.

  • Ico checkbox

    Painkillers have no effect on the pain and I do not use them.

  • Ico checkbox

    I can look after myself normally without causing extra pain.

  • Ico checkbox

    I can look after myself normally but it causes extra pain.

  • Ico checkbox

    It is painful to look after myself and I am slow and careful.

  • Ico checkbox

    I need some help but manage most of my personal care.

  • Ico checkbox

    I need help every day in most aspects of self care.

  • Ico checkbox

    I do not get dressed, I wash with difficulty and stay in bed.

  • Ico checkbox

    I can lift heavy weights without extra pain.

  • Ico checkbox

    I can lift heavy weights but it gives extra pain.

  • Ico checkbox

    Pain prevents me from lifting heavy weights off the floor, but I can manage if they are convenien...

  • Ico checkbox

    Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are...

  • Ico checkbox

    I can lift very light weights.

  • Ico checkbox

    I cannot lift or carry anything at all.

  • Ico checkbox

    My pain is rapidly worsening.

  • Ico multiline

    Comments

  • Ico checkbox

    Pain does not prevent me from walking any distance.

  • Ico checkbox

    Pain prevents me from walking more than one mile.

  • Ico checkbox

    Pain prevents me from walking more than one-half mile.

  • Ico checkbox

    Pain prevents me from walking more than one-quarter mile

  • Ico checkbox

    I can only walk using a stick or crutches.

  • ...and More!

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