1. Do you ever have back pain?
no yes

2. How severe is your back pain?
very mild very severe

3. How often do you experience back pain? Estimate in number of days in the average month.
days per month.

4. Do you spend 6 or more hours of the day sitting at work?
no yes

5. Do you sit more than 30 minutes each way while driving, riding, or commuting to work?
no yes

6. Do you spend more than 1 hour a day sitting for such activities as watching TV, using a computer, or playing games,
no yes

7. Do you exercise?
no yes

8. How many days per week on the average do you exercise (working out, walking, playing sports, etc.)?
days per week.

9. How long, on average, is your typical exercise session (please estimate in minutes per session)?
minutes per session.

10. Please rate the intensity level of your activity from light to heavy. Heavy means that you sweat, your heart rate is rapid,
very light very heavy

11. Describe the type of activity in your typical exercise session (e.g., walking, jogging, weight lifting, yoga, etc.)

12. Do you stretch?
no yes

13. How often do you strech? (Estimate in number of sessions per week)
sessions per week.

14. Please describe your streching activities.

15. Do you have any known disorders of the back or neck?
no yes

16. Please describe your back problem or disorder.

Female
Male

Put 12 for High School Diploma.
Put 16 for college diploma (bachelor's degree, B.A., B.S., etc.).
Put 20 for doctorate degree (Ph.D., M.D., etc).
Education:

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Thank You!