Mid Back Pain Assessment

Is the pain between the shoulder blades or closer to the spine?

Between the shoulder blades

Closer to the spine

Both

Please select an option before proceeding.

Does the pain radiate to your ribs or sides?

Yes, it radiates to the ribs or sides

No, it stays in the back

Please select an option before proceeding.

Do you spend long hours sitting or working at a desk?

Yes, I spend most of my day sitting

Occasionally, I sit for extended periods

No, I am usually on my feet

Please select an option before proceeding.

What type of pain do you feel?

Sharp, sudden pain

Aching, dull pain

Tightness or stiffness

Please select an option before proceeding.

Does the pain improve with stretching or movement?

Yes, movement helps

No, it feels worse with movement

It stays the same

Please select an option before proceeding.

How long have you been experiencing this pain or issue?

Less than a week

1-4 weeks

Over a month

Other

How did the pain start?

Sudden

Gradual

Do you know the cause of pain?

Yes

How would you rate your pain on a scale of 1-10?

Please select an option before proceeding.

Have you taken any medications or treatments for this pain?

Yes

Is this pain the first time you’ve experienced it, or have you had similar pain before?

Yes, this is the first time I’m experiencing this type of pain.

No, I’ve had this type of pain before, but it went away after a while.

No, I’ve had similar pain before, and it has been recurring.

Have you ever been involved in a road traffic accident (car, bike, or pedestrian)?

Yes, I’ve been in a road traffic accident before and sustained injuries.

Yes, but I did not experience significant injuries at the time.

No, I’ve never been in a road traffic accident.

Have you ever had any fractures or discitys in your body, particularly around the affected area?

Yes, I have had a fracture or discity in the area experiencing pain.

Yes, I’ve had a fracture or discity in another area of my body.

No, I’ve never had any fractures or discitys.

Have you undergone any surgeries in the past, especially related to the area experiencing pain?

Yes, I’ve had surgery in the affected area (e.g., hip, shoulder, back).

Yes, I’ve had surgeries elsewhere in my body but not in the affected area.

No, I have never had any surgeries.

Do you have any other medical conditions that might be related to the pain, such as arthritis, diabetes, or autoimmune disorders?

Yes, I have a medical condition (e.g., arthritis, diabetes, fibromyalgia) that may be related to the pain.

No, I don’t have any known medical conditions related to the pain.

I’m not sure, but I’ve been diagnosed with other health issues.

Personal Details

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Last Name

Body Type

Age

Minor Name

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Mid Back Pain Assessment

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