Lower Back Pain Assessment Form
Patient Information
Full Name
Date of Birth
Gender
Female
Male
Other
Pain Assessment
Onset of Pain
Pain Location
Duration of Pain
Pain Intensity (0-10)
Character of Pain (e.g., sharp, dull, throbbing)
Aggravating Factors
Relieving Factors
Associated Symptoms
Describe any associated symptoms (e.g., numbness, tingling, weakness)
Medical History
Relevant Medical/Surgical History
Social History
Occupation
Physical Activity Level
Additional Comments