Roland-Morris Disability Rating Scale for Back Pain
Dr. Frank Bendiks, DC, FACO (630) 301-0054 office; (630) 449-7860 fax
Please answer "Y" yes or "N" no to the following statements:
Patient Name (required)
*
First Name
Last Name
I stay at home most of the time because of the pain in my back.
Y
N
I change position frequently to try and make my back comfortable.
Y
N
I walk more slowly than usual because of the pain in my back.
Y
N
Because of the pain in my back, I am not doing any of the jobs that I usually do around the house.
Y
N
Becasue of the pain in my back, I use a handrail to get upstairs.
Y
N
Because of the pain in my back, I lie down to rest more often.
Y
N
Because of the pain in my back, I have to hold on to something, to get out of a reclining chair.
Y
N
Because of the pain my back, I ask other people to do things for me.
Y
N
I get dressed more slowly than usual because of the pain in my back.
Y
N
I only stand up for short periods of time because of the pain in my back.
Y
N
Because of the pain in my back, I try not to bend or kneel down.
Y
N
I find it difficult to get out of a chair because of the pain in my back.
Y
N
My back hurts most of the time.
Y
N
I find it difficult to turn over in bed because of the pain in my back.
Y
N
My appetite is not very good because of the pain in my back.
Y
N
I have trouble putting on my socks (or stockings) because of the pain in my back.
Y
N
I only walk short distances because of the pain in my back.
Y
N
I sleep less because of the pain in my back
Y
N
Because of the pain in my back, I get dressed with help from someone else.
Y
N
I sit down most of the day because of the pain in my back.
Y
N
I avoid heavy jobs around the house because of the pain in my back.
Y
N
Because of the pain in my back I am more irritable and bad tempered with people.
Y
N
Because of the pain in my back, I go upstairs more slowly than usual.
Y
N
I stay in bed most of the time because of the pain in my back.
Y
N
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