Roland-Morris Disability Questionnaire

Your answers stay on this device until you press Submit. If you press Submit, the completed form is sent over a secure connection and faxed to our office. You can also print the page or save it as a PDF instead.

Patient details

Patient name

Date of birth

Today's date

Needed if you submit the form to our office.

When your back hurts, you may find it difficult to do some of the things you normally do. This list has sentences that people have used to describe themselves when they have back pain. For each sentence, mark Yes if it describes you today, or No if it does not. Think about how you feel today.

Your Roland-Morris score

Disability score0 / 24

Lower is better. The score is the number of statements you mark Yes (0 to 24). A higher score means more disability from low back pain.

Send your form to our office

When your form is complete, press Submit. It is faxed securely to our office.

All forms

Other forms: Oswestry Disability Index (ODI) · PROMIS Physical Function and Pain Interference

Roland-Morris Disability Questionnaire (RMDQ). This form is for patients of Garden State Medical Center. It is not a diagnosis or medical advice. Your provider will review your scores with you.

Roland-Morris Low Back Pain and Disability Questionnaire

Your Roland-Morris score

Send your form to our office

Talk with a GSMC specialist