Scoliosis Patient Questionnaire

Patient Name: _________________

Age: _______

DOB ________

Medical Record #:__________

SS#: ______________

Sex: ( ) M or ( ) F


3 mos.	1 year	____years

The doctors are carefully evaluating the condition of your back 
before and after your treatment. Please circle the one best 
answer to each question unless otherwise indicated. If you 
already have had treatment, please complete sections 1 and 2; 
otherwise, just complete section 1. Results will be kept 
strictly confidential.

On 1 - All patients complete this section. 

On a scale of 1 to 9 with 1 meaning "no pain" and 9 
meaning "severe pain" indicate the degree of pain 
you experience regularly. 

(1)   (2)   (3)	  (4)   (5)   (6)   (7)   (8)   (9)

Using the same scale, indicate the most severe degree 
of pain you have experienced over the last month

(1)   (2)   (3)   (4)   (5)   (6)   (7)   (8)   (9)

If you had to spend the rest of your life with your 
back as it is right now, how would you feel about it?

-Very happy 
-Somewhat happy
-Neither happy nor unhappy
-Somewhat unhappy
-Very unhappy

What is your current level of activity?

-Primarily no activity
-Light labor, such as household chores
-Moderate manual labor and moderate sports, such as walking and biking
-Full activities without restriction

How do you look in clothes?

-Very good
-Very bad

Do you experience back pain when at rest?

-Very often

What is your current level of work/school activity?

-100% normal
-75% normal
-50% normal
-25% normal
-  0% normal

What medications, if any, are you currently taking for your back? 
(Circle all that apply)

-Non-steroidals (ie Motrin)
-Steroids (cortisone)
-Muscle Relaxants (Valium)
-Narcotics (Morphine)

Does your back limit your ability to do things around the house?	 

Yes	No

Have you taken any sick days from work/school due to back pain?	

Yes	No

Do you feel that your condition affects your personal 
relationships with friends and family?     

Yes     No

Are your family experiencing financial difficulties 
because of your back?   

None   Some   Less

Do you go out more or less than your friends?	

More	Same	Less

Do you feel attractive?

-Yes, very
-Yes, somewhat
-Neither attractive nor unattractive
-No, not very much
-No, not at all

On a scale of 1 to 9, with 1 being very low and 9 being 
extremely high, how would you rate your self-image?	

(1)   (2)   (3)   (4)   (5)   (6)   (7)   (8)   (9)

Section 2- Post-treatment patients only.

Has your back treatment changed your function and daily activities? 

( ) Increased ( ) Not changed ( ) Decreased

Has your back treatment changed your ability to enjoy 

( ) Increased  ( ) Not changed ( ) Decreased

Has your back treatment_______________ your back pain? 

( ) Increased  ( ) Not changed  ( ) Decreased

Has your treatment changed your confidence in personal 
relationships with others? 

( ) Increased  ( ) Not changed ( ) Decreased

Has your treatment changed the way others view you?

-Much Better
-Much Worse

Has your treatment changed your self-image?  

( ) Increased  ( ) Not changed  ( ) Decreased

Are you satisfied with the results of your back 

-Extremely satisfied
-Somewhat satisfied
-Neither satisfied nor dissatisfied
-Somewhat dissatisfied
-Extremely dissatisfied

Compared to before your treatment, how do you feel 
you now look?

-Much better
-Much Worse

Would you have the same treatment again if you 
had the same condition?

-Definitely yes
-Probably yes
-Not sure
-Probably not
-Definitely not

Thank you for completing this questionnaire.     

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