telmagrant_RolandMorris

The Roland-Morris Questionnaire
When your back hurts, you may find it difficult to do some of the things you normally do. This list contains statements that people have

used to describe themselves when they have back pain. When you read them, you may find that some stand out because they describe

you today. As you read the list think of yourself today.

When you read a statement that describes you today, put a check mark in the box to the left of the statement. If the statement does not describe you, then leave the space blank and go on to the next statement.
Questions:

I stay at home most of the time because of my back.I change position frequently to try to get my back comfortable.I walk more slowly than usual because of my back.Because of my back, I am not doing any jobs that I usually do around the house.Because of my back, I use a handrail to get upstairs.Because of my back, I lie down to rest more often.Because of my back, I have to hold on to something to get out of an easy chair.Because of my back, I try to get other people to do things for me.I get dressed more slowly than usual because of my back.I only stand up for short periods of time because of my back.Because of my back, I try not to bend or kneel down.I find it difficult to get out of a chair because of my back.My back is painful almost all of the time.I find it difficult to turn over in bed because of my back.My appetite is not very good because of my back.I have trouble putting on my sock (or stockings) because of the pain in my back.I can only walk short distances because of my back pain.I sleep less well because of my back.Because of my back pain, I get dressed with the help of someone else.I sit down for most of the day because of my back.I avoid heavy jobs around the house because of my back.Because of back pain, I am more irritable and bad tempered with people than usual.Because of my back, I go upstairs more slowly than usual.I stay in bed most of the time because of my back.
Scoring: Each item is worth 1 point. The score equals the number of items checked. Score: Higher=Worse, Lower=Better. Increase=Worsening, Decrease=Improvement

Numerical Pain Rating Scale (NPRS) With respect to your pain, over the last 24 hours, how bad has your pain been?

	No Pain 0	Mild 1-3	Moderate 4	Severe 5-6	Very Severe 7-9	Worst Pain Possible
Select the appropriate number

Patient name
Today's Date

MonthDayYear
Date
Date of birth

MonthDayYear
Date
Should be Empty:

The Roland-Morris Questionnaire