My Back Pain: Check List

I have had pain since _________ Weeks ___________ Months

Since then it has gotten __better ___ worse (Please X the appropriate blank)

My pain starts:

__suddenly __sneaking up on me
__without cause __in certain positions
__at any time __at certain times
__with certain motions __when resting
__frequently __occasionally
__constantly present

The pain is:

__of short duration __long lasting
__constant __grows in intensity
__location specific __radiating
__always equally strong __varing

The pain feels:

__sharp __dull
__like burning __pressing
__like stabbing __blistering
__pulsating __pins and needles