Low Back Pain Disability Questionnaire:

Please fill out the new patient paperwork online and submit to our office prior to your first visit.


Due to COVID-19, we want to minimize patient time spent in the waiting area.  We pride ourselves on maximizing your time with your physical therapist to work one on one and begin the process of recovery.  Paperwork is an unfortunate necessity of the process but we want to minimize this burden and have it done prior to your visit so that we can get your treatment started!

FORM Low Back Pain Disability

Pain Intensity

Personal Care






Social Life



15 + 13 =

Our front office person administrator will inform you of the proper functional outcome to fill out and submit as well.  Your therapist will score this and establish a baseline of how you currently rate your symptoms.

If you need to contact Dr. Damon Daura, the email is: Damon@DamonPT.com

For any questions – please reach out! 
Totowa 973-237-1975   |   Lafayette Township 973-862-6377

This questionnaire has been designed to give your therapist information as to how your ankle problems have affected your functional ability. Please answer every question by placing clicking on the response that best describes your injured ankle compared with the non-injured side.

Check only 1 answer for each question choosing the answer that best describes your injured ankle. We realize you may feel that two of the statements may describe your condition, but please click only the one which closely describes your current condition.