Skip to content
Home
Programs
Personal Training
Yoga
Assisted Stretching
Health Coaching
Packages
Request Pricing
Blog
About
Other
FAQ
Store
Questionnaires
Client Information and Waiver
Posture Information and Waiver
Posture Back and Neck Assesment
Peerfit
Contact
Home
Programs
Personal Training
Yoga
Assisted Stretching
Health Coaching
Packages
Request Pricing
Blog
About
Other
FAQ
Store
Questionnaires
Client Information and Waiver
Posture Information and Waiver
Posture Back and Neck Assesment
Peerfit
Contact
Posture Back and Neck Assesment
Welcome! Please answer the questions below.
Name
Date
Back Bournemouth Questionnaire
Instructions: The following scales have been designed to find out about your back pain and how it is affecting you. Please answer ALL the scales, and mark the ONE number on EACH scale that best describes how you feel.
1. Over the past week, on average, how would you rate your back pain? 0 = No pain, 10 = Worst pain possible
0
1
2
3
4
5
6
7
8
9
10
2. Over the past week, how much has your back pain interfered with your daily activities (housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)? 0 = No interference, 10 = Unable to carry out activity
0
1
2
3
4
5
6
7
8
9
10
3. Over the past week, how much has your back pain interfered with your ability to take part in recreational, social, and family activities? 0 = No interference, 10 = Unable to carry out activity
0
1
2
3
4
5
6
7
8
9
10
4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have you been feeling? 0 = Not at all anxious, 10 = Extremely anxious
0
1
2
3
4
5
6
7
8
9
10
5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling? 0 = Not at all depressed, 10 = Extremely depressed
0
1
2
3
4
5
6
7
8
9
10
6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would affect) your back pain? 0 = Have made it no worse, 10 = Have made it much worse
0
1
2
3
4
5
6
7
8
9
10
7. Over the past week, how much have you been able to control (reduce/help) your back pain on your own? 0 = Completely control it, 10 = No control whatsoever
0
1
2
3
4
5
6
7
8
9
10
PLEASE RECORD THE TOTAL SCORE IN THE SPECIFIED SECTION BELOW.
Back Assessment Total Score
Please calculate the sum of all numerical values from your responses. This metric will serve as a benchmark for comparative analysis. Subtle variations in your responses could have noteworthy implications for your overall well-being.
Neck Bournemouth Questionnaire
Instructions: The following scales have been designed to find out about your neck pain and how it is affecting you. Please answer ALL the scales, and mark the ONE number on EACH scale that best describes how you feel.
1. Over the past week, on average, how would you rate your neck pain? 0 = No Pain, 10 = Worst pain possible
0
1
2
3
4
5
6
7
8
9
10
2. Over the past week, how much has your neck pain interfered with your daily activities (housework, washing, dressing, lifting, reading, driving)? 0 = No interference, 10 = Unable to carry out activity
0
1
2
3
4
5
6
7
8
9
10
3. Over the past week, how much has your neck pain interfered with your ability to take part in recreational, social, and family activities? 0 = No interference, 10 = Unable to carry out activity
0
1
2
3
4
5
6
7
8
9
10
4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have you been feeling? 0 = Not at all anxious, 10 = Extremely anxious
0
1
2
3
4
5
6
7
8
9
10
5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling? 0 = Not at all depressed, 10 = Extremely depressed
0
1
2
3
4
5
6
7
8
9
10
6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would affect) your neck pain? 0 = Have made it no worse, 10 = Have made it much worse
0
1
2
3
4
5
6
7
8
9
10
7. Over the past week, how much have you been able to control (reduce/help) your neck pain on your own? 0 = Completely control it, 10 = No control whatsoever
0
1
2
3
4
5
6
7
8
9
10
PLEASE RECORD THE TOTAL SCORE IN THE SPECIFIED SECTION BELOW.
Neck Assessment Total Score
Please calculate the sum of all numerical values from your responses. This metric will serve as a benchmark for comparative analysis. Subtle variations in your responses could have noteworthy implications for your overall well-being.
Submit
