Form 3 Self-reported low back pain questionnaire

Form Approved

OMB No. 0920-XXXX

Exp.Date: xx/xx/20xx

Attachment H-1:

Self-reported low back pain

(NASS Lumbar Spine Outcome Assessment Instrument) (17 items)

This questionnaire will be completed by all participating employees at the start of the study and every 3 months for 2 years.

The following questions are about how you have felt, on average, during the past week.

1a. In the past week, how often have you suffered low back and/or buttock pain?

• N one of the time Go to Question 2a

• A little of the time

• Some of the time

• A good bit of the time

• Most of the time

• All of the time

1b. How bothersome has the low back and/or buttock pain been?

• Not at all bothersome

• Slightly bothersome

• Somewhat bothersome

• Moderately bothersome

• Very bothersome

• Extremely bothersome

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden estimate to CDC/ASTDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

2a. In the past week, how often have you suffered leg pain?

• N one of the time Go to Question 3a

• A little of the time

• Some of the time

• A good bit of the time

• Most of the time

• All of the time

2b. How bothersome has the leg pain been?

• Not all bothersome

• Slightly bothersome

• Somewhat bothersome

• Moderately bothersome

• Very bothersome

• Extremely bothersome

3a. In the past week, how often have you suffered numbness or tingling in leg and/or foot?

• N one of the time Go to Question 4a

• A little of the time

• Some of the time

• A good bit of the time

• Most of the time

• All of the time

3b. How bothersome has the numbness or tingling in leg and/or foot been?

• Not at all bothersome

• Slightly bothersome

• Somewhat bothersome

• Moderately bothersome

• Very bothersome

• Extremely bothersome

4a. In the past week, how often have you suffered weakness in leg and/or foot?

• N one of the time Go to Question 5

• A little of the time

• Some of the time

• A good bit of the time

• Most of the time

• All of the time

4b. How bothersome has the weakness in leg and/or foot been?

• Not at all bothersome

• Slightly bothersome

• Somewhat bothersome

• Moderately bothersome

• Very bothersome

• Extremely bothersome

5. In the past week, how has pain affected you when you get dressed?

• I can dress myself without pain.

• I can dress myself without increasing pain.

• I can dress myself but pain increases.

• I can dress myself but with significant pain.

• I can dress myself but with very severe pain.

• I cannot dress myself due to pain.

6. In the past week, how has pain affected you when you lift something?

• I can lift heavy objects without pain.

• I can lift heavy objects but it is painful

• Pain prevents me from lifting heavy objects off the floor, but I can lift heavy objects if they are on a table.

• Pain prevents me from lifting heavy objects off the floor, but I can lift light to medium objects if they are on a table.

• I can only lift light objects due to pain.

• I cannot lift anything due to pain.

7. In the past week, how has pain affected you when you are walking and running?

• I can walk or run without pain.

• I can walk comfortably, but running is painful.

• Pain prevents me from walking more than 1 hour.

• Pain prevents me from walking more than 30 minutes.

• Pain prevents me from walking more than 10 minutes.

• I am unable to walk or can walk only a few steps at a time.

8. In the past week, how has pain affected you when you are sitting?

• I can sit in any chair as long as I like.

• I can only sit in a special chair for as long as I like.

• Pain prevents me from sitting more than 1 hour.

• Pain prevents me from sitting more than 30 minutes.

• Pain prevents me from sitting more than 10 minutes.

• Pain prevents me from sitting at all.

9. In the past week, how has pain affected you when you are standing?

• I can stand as long as I want.

• I can stand as long as I want but it gives me pain.

• Pain prevents me from standing more than 1 hour.

• Pain prevents me from standing more than 30 minutes.

• Pain prevents me from standing more than 10 minutes.

• Pain prevents me from standing at all.

10. In the past week, how has pain affected you when you sleep?

• I sleep well.

• Pain occasionally interrupts my sleep.

• Pain interrupts my sleep half of the time.

• Pain often interrupts my sleep.

• Pain always interrupts my sleep.

• I never sleep well.

10. In the past week, how has pain affected your social and recreational life?

• My social and recreational life is unchanged.

• My social and recreational life is unchanged, but it increases pain.

• My social and recreational life is unchanged, but it severely increases pain.

• Pain has restricted my social and recreational life.

• Pain has severely restricted my social and recreational life.

• I have essentially no social and recreational life because of pain.

10. In the past week, how has pain affected your traveling?

• I can travel anywhere.

• I can travel anywhere but it gives me pain.

• Pain is bad but I can manage to travel over 2 hours.

• Pain restricts me to trip of less than 1 hour.

• Pain restricts me to trip of less than 30 minutes.

• Pain prevents me from traveling.

10. In the past week, how has pain affected your sex life?

• My sex life is unchanged.

• My sex life is unchanged, but causes some pain.

• My sex life is nearly unchanged, but it is very painful.

• My sex life is severely restricted by pain.

• My sex life is nearly absent because of pain.

• Pain prevents any sex life at all.