Section 1: Symptom Behavior
1. Your symptoms change with movement or position.
☐ Strongly agree
☐ Somewhat agree
☐ Unsure
☐ Disagree
2. Certain movements clearly make symptoms better or worse.
☐ Strongly agree
☐ Somewhat agree
☐ Unsure
☐ Disagree
3. Your pain is influenced by posture (sitting, standing, lying down).
☐ Strongly agree
☐ Somewhat agree
☐ Unsure
☐ Disagree
Section 2: Pain Location & Quality
4. Your pain is mostly localized (back, neck, shoulder, hip).
☐ Strongly agree
☐ Somewhat agree
☐ Unsure
☐ Disagree
5. If pain travels, it changes with movement or position.
☐ Strongly agree
☐ Somewhat agree
☐ Unsure
☐ Disagree
☐ Not applicable
6. Your pain feels achy, tight, sore, or stiff more than sharp or electric.
☐ Strongly agree
☐ Somewhat agree
☐ Unsure
☐ Disagree
Section 3: Load & Activity Response
7. Symptoms relate to how much activity you do (too much or too little).
☐ Strongly agree
☐ Somewhat agree
☐ Unsure
☐ Disagree
8. Warming up or moving differently sometimes improves symptoms.
☐ Strongly agree
☐ Somewhat agree
☐ Unsure
☐ Disagree
9. Symptoms flare after sudden increases in activity or new tasks.
☐ Strongly agree
☐ Somewhat agree
☐ Unsure
☐ Disagree
Section 4: Neurological Red Flags (Screening Only)
10. You have progressive weakness in an arm or leg.
☐ Yes
☐ No
11. You have worsening numbness or tingling that does not change with movement.
☐ Yes
☐ No
12. You have bowel or bladder changes, or constant unrelenting pain.
☐ Yes
☐ No