Print out, complete and bring this form to your doctor – this information will greatly assist in the diagnosis and treatment of your back pain.

When did your pain start? __________

If you are one of the estimated 100,000 Canadians who will be diagnosed this year with a contained herniated disc – also known as a ‘thrown-out back’ or ‘pinched nerve’ of the upper leg – the answer may be as familiar as your radio.

You’ve probably heard people say they have a "slipped" or "ruptured" disk in the back. What they’re actually describing is a herniated disk, a common source of lower back pain.


If you are taking care of a spouse or family member at home, you are at greatest risk for back pain when you are:

Some basic tips you will find useful in preventing back injury at work and at home

Regular exercise is your most potent weapon against back problems.

If you suddenly start feeling pain in your lower back or hip that radiates down from your buttock to the back of one thigh and into your leg, your problem may be a protruding disk in your lower spinal column pressing on the roots to your sciatic n

Healing will occur most quickly if you can continue your usual activities in a gentle manner while avoiding what may have caused the pain in the first place.

Back pain is a symptom that can arise from many causes. It can range from a dull, annoying ache to absolute agony. Many cases of back pain are caused by stresses on the muscles and ligaments that support the spine.

Low back pain is one of the most frequent problems treated by doctors. Four out of five adults will experience significant low back pain sometime during their life.

A diary/log used to rate the effectiveness of the (or each of the) medications you may be using for your pain.


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