Scroll down for
more questions.
Back to Tools
The SIMPLE (Screening for InflaMmatory Pain in the LowEr) Back Questionnaire
Thank you for filling in this questionnaire. It asks questions about the back, buttock, and/or hip pain that you have experienced.
Please enter your birthday (month and year):
January
February
March
April
May
June
July
August
September
October
November
December
1. Have you had any discomfort in your back, buttocks, or hips
in the last three months
?
Yes
No
If no, have you
ever
had pain in your back, buttocks, or hips that lasted for at least 3 months?
Yes
No
If you have had back, buttock, or hip pain that lasted for
at least 3 months
(the last 3 months or in the past), please indicate when you first experienced these symptoms.
A. Over 40 years of age
B. 30-40 years of age
C. 20-30 years of age
D. Less than 20 years of age
2. Do you experience stiffness in your back and/or hips?
Yes
No
If yes, when is this
MOST
noticeable? Please tick only
ONE
option:
A. When I get out of bed
B. Afternoon
C. Evening
D. No consistent time
3. If you are stiff when you get out of bed, how long does it
USUALLY
take from when you get out of bed until your back and/or hips are moving as well as they are going to move all day?
Please tick the closest time.
A. 10 minutes or less
B. 30 minutes
C. 60 minutes or more
D. Not applicable-I am not stiff when I get out of bed
4. Have you been woken up by back and/or hip pain during sleep in the last few months? Please tick only
ONE
option.
A. Often
B. Sometimes
C. Almost Never
If this happens at least sometimes, when does it
USUALLY
wake you up? Please tick
only one
option.
Early after going to sleep
After several hours of sleep
5. At what time of day are your back and/or hip symptoms
USUALLY
the worst? Please tick only
ONE
option:
A. Morning
B. Afternoon
C. Evening
D. Night
E. Not Applicable
6. Have you ever had painful and swollen joints?
Yes
No
If yes, what joints?
7. What effect does exercise have on your back and/or hip pain or stiffness? Please tick only
ONE
option.
A. Usually makes it worse
B. No consistent effect
C. Usually makes it better
8. What effect does lying down and taking a rest have on your back and/or hip pain or stiffness? Please tick only
ONE
option.
A. Usually makes it worse
B. No consistent effect
C. Usually makes it better
9. Do Anti-inflammatory drugs ( eg. Advil, Motrin, Ibuprofen, Arthrotec, Celebrex, Naproxen, Diclofenac)
USUALLY
ease your back and/or hip pain and stiffness?
Yes
No
Do not use these drugs for these symptoms
Have not tried these drugs for these symptoms
10. Do you suffer from any of the following:
A.
Daily
Headaches
Yes
No
B. Chronic fatigue
Yes
No
C. Irritable bowel syndrome
Yes
No
D.
Daily
jaw pain
Yes
No
