I am now going to ask you a series of questions about the effects that [INSERT TREATMENT MODALITY] may have on your back pain and how back pain impacts your life. In each case, the question is asking about the results at the end of the treatment period.
1.How much change do you hope for in your back pain? Please answer on a scale of 0 to 10, where 0 is “no change or worse” and 10 is “complete relief.”
 0  1  2  3  4  5  6  7  8  9  10
 No Change/Worse                 Complete Relief
2.How much change do you realistically expect in your back pain? Please answer on a scale of 0 to 10, where 0 is “no change or worse” and 10 is “complete relief.”
 0  1  2  3  4  5  6  7  8  9  10
 No Change/Worse                 Complete Relief
3.How much change do you realistically expect in the impact of back pain on your life? Please answer on a scale of 0 to 10, where 0 is “no change or worse”, and 10 is “pain no longer impacts my life.”
 0  1  2  3  4  5  6  7  8  9  10
 No Change/Worse                 Back Pain No Longer Impacts My Life
4.How much change do you realistically expect in the impact of back pain on your daily activities? Please answer on a scale of 0 to 10, where 0 is “no change or worse” and 10 is “back pain no longer impacts my daily activities.” Or you may choose “not applicable” if back pain does not impact your daily activities now.
 0  1  2  3  4  5  6  7  8  9  10
 No Change /Worse                 Back Pain No Longer Impacts My Daily Activities
 □ Not Applicable
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