Keele STarT Back Screening Tool - fvfiles.com

1 Keele STarT back Screening tool Patient name: _____ Date/Time _____/_____Thinking about the last 2 weeks, check off your response to the following questions:Disagree (0)Agree (1)1. My back pain has spread down my leg(s) at some time in the last two weeks. 2. I have had pain in the shoulder or neck at some time in the last two weeks. 3. I have only walked short distances because of my back pain. 4. I have dressed more slowly than usual because of back pain. 5. It s not really safe for a person with my condition to be physically active. 6. Worrying thoughts have been going through my mind a lot of the time.

2 7. I feel that my back pain is terrible and it s never going to get any better. 8. In general I have not enjoyed all the things I used to enjoy. 9. Overall, how bothersome has your back pain been in the last 2 weeks?Not at allSlightlyModeratelyVery muchExtremely 00011 Total score (all 9): _____ Sub Score (Q5-9):_____For informational purposes only. Not to replace the advice of your health care provider. Fairview Health Services. Copyright 2012. All rights reserved. Keele STarT back Screening tool Keele University 01/08/07. Funded by Arthritis Research UK. Reprinted with permission. SMART works 521447 09 1 of 2 Pain ScalePlease rate your pain on a scale of 0 to 10, where 0 means no pain and 10 means severe pain (so severe that you couldn t live with it for more than a few minutes).

3 Place a mark on the lines below to show how much pain you ve had during the last PainNo pain Severe painGlobal Rating ScalePlease rate your injury from the time you began treatment until now. -5 -4 -3 -2 -1 0 1 2 3 4 5 Much worse No change Much better If you are deaf or hard of hearing, please let us know. We provide many free services including sign language interpreters, oral interpreters, TTYs, telephone amplifiers, note takers and written 2 of 2