Download Low Back Pain Screening Questionnaire

APPENDIX 21
LBP SCREENING QUESTIONNAIRE
Patient’s name:
CHI number :
Completed by:
Date:
Signature:
Low back pain screening questionnaire
(See separate glossary for more details)
Please if  if no problems, X if a problem (Do not leave blanks)
Hierarchy Health parameters
of Red Flags
 or X
Comments
Age <20 >55
General health
Recent investigations/hospital
appointments
Major surgery
Medication history
Steroid use/osteoporosis
Anticoagulants
Statins
Diabetic
Epileptic
Cardiovascular problems
Does the patient have a history
of high blood pressure?
Previous strokes/TIA
Respiratory problems
Persistent cough
Infection, fevers, viruses
HIV/ drug abuse
Night sweats
Weight loss
Thoracic pain
History of cancer
History of rheumatoid arthritis
Other joint pains
Allergies - latex
-elastoplast
Greenhaugh & Selfe (2006) Red Flags. A Guide to Identifying Serious Spinal Pathology of the Spine. Elsevier, Edinburgh)
Patient’s Name:
CHI Number:
Please if  if no problems, X if a problem (Do not leave blanks)
Cauda Equina Syndrome
This is a medical emergency and the patient needs to be
referred immediately to Accident & Emergency
 or X
Comments
Bladder bowel frequency
altered from normal?
Bowel frequency
altered from normal?
Saddle anaesthesia or
paraesthesia present?
Urinary and/or faecal
incontinence present?
See Cauda Equina triage chart in glossary for additional information and actions
Please if  if no problems, X if a problem (Do not leave blanks)
Yellow flags
Have these flags
been considered?
 or X
Comments
Attitudes/beliefs
Behaviours
Compensation
issues
Diagnosis
Emotions
Family
Work
Acknowledgements
Red Flags:
Cauda Equina:
Dr Orla Crummey, NHS Lothian
Greater Glasgow Back Pain Service
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