1. Have you read information about your symptoms on Patient.info?

Yes

No

2. Have you injured your back?

Yes

No

3. Do you currently have back pain?

Yes

No

4. Would you describe your back pain as upper or lower back?

5. How would you rate your back pain on a scale of 1-10 (1 being the least painful and 10 being the most painful)?

6. Please describe your symptoms:

7. How long have you had these current back symptoms?

8. Does your back pain wake you up in the night?

Yes

No

9. Are you able to walk without assistance?

Yes

No

10. Are you confined to bed as a result of your back pain?

Yes

No

11. Have you been diagnosed with a back problem by a doctor?

Yes

No

12. Does your back pain go down one leg?

Yes

No

13. Does your back pain go down both legs?

Yes

No

14. Do you have loss of bladder control?

Yes

No

15. Do you have difficulty passing urine?

Yes

No

16. Do you have loss of bowel control?

Yes

No

17. Do you have any numbness around your anus or behind the genitalia?

Yes

No

18. Have you had any unexplained weight loss recently?

Yes

No

19. During this illness have you had a fever?

Yes

No

20. Have you had any operations on your back?

Yes

No

21. Have you had any previous fractures (break) of the spine?

Yes

No

22. Have you ever been diagnosed with osteoporosis?

Yes

No

23. Have you ever had prostate, bladder, breast, thyroid or lung cancer?

Yes

No

24. Have you had any investigations relating to this condition?

Yes

No

25. Is there anything else you would like to tell us that has not been asked in the previous questions?

26. Do all of the following apply to you?

• I will read the patient information leaflet supplied with my medication.
• The medication is for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)

Yes

No