Keele STarT Back Score

If you have been advised by the surgery to submit a Keele STarT Back Score assessment please use this form.

Keele STarT Back Score

If you are human, leave this field blank.

About You

Patient First Name: *

Patient Last Name: *

Patient Date of Birth: *

Please use this date format: DD/MM/YYYY.

Contact Number: *

Email: *

Any responses we send will go to this email address.

Keele STarT Back Screening

Thinking about the last 2 weeks tick your response to the following questions:

My back pain has spread down my leg(s) at some time in the last 2 weeks *

Disagree

Agree

I have had pain in the shoulder or neck at some time in the last 2 weeks *

Disagree

Agree

I have only walked short distances because of my back pain *

Disagree

Agree

In the last 2 weeks, I have dressed more slowly than usual because of back pain *

Disagree

Agree

It’s not really safe for a person with a condition like mine to be physically active *

Disagree

Agree

Worrying thoughts have been going through my mind a lot of the time *

Disagree

Agree

I feel that my back pain is terrible and it’s never going to get any better *

Disagree

Agree

In general I have not enjoyed all the things I used to enjoy *

Disagree

Agree

Overall, how bothersome has your back pain been in the last 2 weeks? *

Not at all

Slightly

Moderately

Very much

Extremely

Total Score

This is your total score from all 9 questions

Sub Score

This is your sub score from questions 5-9

Please note that the details you give will be used to update your medical records.

*

I confirm that the information provided is accurate to the best of my knowledge