Red Flags Test | Disability Assessment

1. What is your age?

If age <= 20
If age > 20 and age < 50
If age >= 50

2. Have you got a history of any malignancies (cancers or tumors)?

Yes
No

3. Have you noticed any unexplained weight loss?

Yes
No

4. Have you had any treatment for your back pain, which failed to improve it after a month of the therapy?

Yes
No

5. Have you ever had an organ transplant?

Yes
No

6. Are you HIV positive (AIDS)?

Yes
No

7. Have you ever been treated with any immunosuppression therapy (treatment that reduces the activation or efficacy of the immune system - chemotherapy, radiotherapy, or use of drugs like platinum, cyclophosphamide, nitrosoureas, methotrexate, azathioprine, mercaptopurine, pyrimidine analogs, anthracyclines, mitomycin C, bleomycin, mithramycin)?

Yes
No

8. Have you ever been treated with steroids and/or used steroids (this does not include inhaled steroids - i.e. used for asthma)?

Yes
No

9. Do you, have diabetes?

Yes
No

10. Have you had any surgery within the last 4 months?

Yes
No

11. Have you recently had (or still have) any skin or tooth infection?

Yes
No

12. Have you recently had (or still have) a urinary tract ("water-work") infection?

Yes
No

13. Have you recently had (or still have) any infection?

Yes
No

14. Have your ever used intravenous drugs (i.e. injected drugs like heroin etc)?

Yes
No

15. Have you got a history of any serious trauma (Road traffic accidents, serious falls, serious work injuries, etc.)?

Yes
No

16. Have you recently had any surgery on your urinary tract ("water-work" like kidneys, bladder, prostate, urethra, etc)?

Yes
No

17. Have you ever had any spinal surgery?

Yes
No

18. Have you ever been (even occasionally) incontinent of urine? (unable to control your "water-work"?)

Yes
No

19. Are you able to pass urine as normal and are you able to completely empty your bladder to completion?

Yes
No

20. Have you ever had any fecal incontinence? (unable to control your bowels?)

Yes
No

21. Have you noticed a decreased sensation ("reduction of feeling") in the saddle region (private area)?

Yes
No

22. Do you trip frequently or have frequent falls?

Yes
No

23. Have you noticed any weakness in one or both legs?

Yes
No

24. Have you noticed any weakness in one or both feet?

Yes
No

25. Have you noticed any tenderness (pain on touching) in your back?

Yes
No

26. Have you been suffering from chills or fevers (temperature above 38 C or above 100 F) recently?

Yes
No

27. Have you noticed any sexual dysfunction like a poor erection?

Yes
No

28. Have you ever had a spinal or vertebral (e.g. "back-bone") fracture?

Yes
No

29. Do you suffer from constant (unrelenting) pain while at rest?

Yes
No

30. How would you grade the pain on a scale of 1-10 (10 is the worst possible pain experienced)?