Roland-Morris Disability Questionnaire

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The Roland-Morris Disability Questionnaire is an excellent, short, questionnaire for following the progress of a patient’s functional improvement with low back pain over time.  It is particularly effective for acute and subacute patients.  Every 1-2 weeks, the patient is asked to filled out the questionnaire.

The patient ‘checks’ each applicable statement (24 total) for him/her on that day.  The total “checked” is recorded and followed over time to show the patient’s functional progress.

The form is below, but can also be downloaded here: Roland-Morris Disability Questionnaire [It is considered “public domain”, and no permission is required for its use or reproduction.]


Patient name: ____________________________________ File # __________ Date: __________

Please read instructions: when your back hurts, you may find it difficult to do some of the things you normally do. Mark only the sentences that describe you today.

[ ]   I stay at home most of the time because of my back.

[ ]   I change position frequently to try to get my back comfortable.

[ ]   I walk more slowly than usual because of my back.

[ ]   Because of my back, I am not doing any jobs that I usually do around the house.

[ ]   Because of my back, I use a handrail to get upstairs.

[ ]   Because of my back, I lie down to rest more often.

[ ]   Because of my back, I have to hold on to something to get out of an easy chair.

[ ]   Because of my back, I try to get other people to do things for me.

[ ]   I get dressed more slowly than usual because of my back.

[ ]   I only stand up for short periods of time because of my back.

[ ]   Because of my back, I try not to bend or kneel down.

[ ]   I find it difficult to get out of a chair because of my back.

[ ]   My back is painful almost all of the time.

[ ]   I find it difficult to turn over in bed because of my back.

[ ]   My appetite is not very good because of my back.

[ ]   I have trouble putting on my sock (or stockings) because of the pain in my back.

[ ]   I can only walk short distances because of my back pain.

[ ]   I sleep less well because of my back.

[ ]   Because of my back pain, I get dressed with the help of someone else.

[ ]   I sit down for most of the day because of my back.

[ ]   I avoid heavy jobs around the house because of my back.

[ ]   Because of back pain, I am more irritable and bad tempered with people than usual.

[ ]   Because of my back, I go upstairs more slowly than usual.

[ ]   I stay in bed most of the time because of my back.

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