BODY CHART past two weeks – Researcher please check the box(es) at the bottom of the chart to show any areas where the participant has experienced pain in the past two weeks. P = ////// Have you experienced any back pain in the last two weeks? (Please tick) Yes No Lower lumbar (L3, L4, L5), Mid-Lumbar (L1, L2), Lower Thoracic Pain Site (T6 -T12) Upper Thoracic (T1-T5) Mark on the scale below the severity of any back pain in the last two weeks. 0 1 2 3 4 5 6 7 8 9 10 No pain Trial pain Imaginable BODY CHART Today – Researcher please check the box(es) at the bottom of the chart to show any areas where the participant has experienced pain today. P = ////// Do you have any back pain today? (Please tick) Yes No Pain Site Lower lumbar (L3, L4, L5), Mid-Lumbar (L1, L2), Lower Thoracic (T6 -T12) Upper Thoracic (T1-T5) Mark on the scale below the severity of any back pain is today.
BODY CHART – past two weeks Researcher please check the box(es) at the bottom of the chart to show any areas where the participant has experienced pain in the past two weeks. P = ////// Have you experienced any back pain in the last two weeks? (Please tick) Yes No Pain Site Lower lumbar (L3, L4, L5), Mid-Lumbar (L1, L2), Lower Thoracic (T6 -T12) Upper Thoracic (T1-T5) Mark on the scale below the severity of any back pain in the last two weeks. 0 1 2 3 4 5 6 7 8 9 10 No pain pain Imaginable BODY CHART – Today Researcher please check the box(es) at the bottom of the chart to show any areas where the participant has experienced pain today. P = ////// Do you have any back pain today? (Please tick) Yes No Pain Site Lower lumbar (L3, L4, L5), Mid-Lumbar (L1, L2), Lower Thoracic (T6 -T12) Upper Thoracic (T1-T5) Mark on the scale below the severity of any back pain is today. Trial
Case_Report_Form_PROVE.docx