Low Back Pain Questionnaire
What a low back pain questionnaire asks in a pain clinic, with sample questions for clinic staff.
A low back pain questionnaire records back and leg pain, which positions change it, and past imaging and injections before a pain clinic visit. The questions here come from low back items on Main Line Health and UCLA Health spine intake forms.
Low back pain questionnaire, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a low back pain questionnaire in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample low back pain questionnaire questions
Questions built from spine intake forms, written out so you can see the level of detail. Every practice words its own form differently.
- How much of your pain is in your back?Pain areas
- Is your back or your leg worse?Pain areas
- Is it worse standing, sitting, or walking?Body position
- Which position gives you the least pain?Body position
- Is it worse when you first get up?Daily pattern
- Is it worse at the end of the day?Daily pattern
- Have you had an MRI of your lower back?Imaging tests
- Have you had a CT scan or X-ray?Imaging tests
- Have you had a steroid injection for this?Injections
- Did the injection help?Injections
- Has physical therapy helped your back?Other treatments
- What pain medicines are you using now?Other treatments
These are examples to read, not a form to fill in.
Low back pain questionnaire: FAQ
What does a low back pain questionnaire ask?
The sample questions on this page are based on the Main Line Health spine intake form and the UCLA Health Spine New Patient Questionnaire. This page groups them into six areas: pain areas, body position, daily pattern, imaging tests, injections, and other treatments.
Who fills in a low back pain questionnaire, and when?
A new patient with back pain, as part of clinic paperwork. The UCLA Health form opens by asking patients to answer a few questions about their symptoms.
Is it the same as a back pain intake?
It can be. A multispecialty group's pain and spine intake form works as one, with lower back pain as a checkbox among other problems.
How does it separate back pain from leg pain?
The Main Line Health form asks patients to give each area a percentage, as if all their pain equals 100 percent.
Does it ask about earlier injections?
Yes. The UCLA Health form asks whether the patient has had a steroid injection, when, and whether it helped.
What happens after the low back pain questionnaire is completed?
A clinician at the pain clinic reads the answers. AI Doctor only collects them and doesn't suggest imaging or injections.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
