Back Pain Functional Scale
Please answer every question with one response that most closely describes your condition within the past week.

Each answer will be scored between 0-5:

0 = unable to perform activity
1 = extreme difficulty
2 = quite a bit of difficulty
3 = moderate difficulty
4 = a little bit of difficulty
5 = no difficulty
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First and Last Name *
Usual work and household activities
unable to perform
no difficulty
Clear selection
Usual hobbies and recreational activities
unable to perform
no difficulty
Clear selection
Performance of heavy activities around the home
unable to perform
no difficulty
Clear selection
Bending or stooping
unable to perform
no difficulty
Clear selection
Putting on shoes and socks
unable to perform
no difficulty
Clear selection
Lifting a box of groceries from the floor
unable to perform
no difficulty
Clear selection
Sleeping
unable to perform
no difficulty
Clear selection
Standing for 1 hour
unable to perform
no difficulty
Clear selection
Walking 2km (1.2 miles)
unable to perform
no difficulty
Clear selection
Walking 10km (6.2 miles)
unable to perform
no difficulty
Clear selection
Going up and down 2 flights of stairs (about 20 steps)
unable to perform
no difficulty
Clear selection
Sitting for 1 hour
unable to perform
no difficulty
Clear selection
Driving for 1 hour
unable to perform
no difficulty
Clear selection
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