Québec Back Pain Disability Scale
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Use our readymade template to create your Québec Back Pain Disability Scale (QBPDS) for assessing the severity of disability in patients with back pain

Create your care assessments

QBPDS score Disability Severity
0-20 Minimal
21-40 Mild
41-60 Moderate
Severe
Very Severe
  • navigate_next Prebuilt template with QBPDS scoring to assess the presence of back pain and measure its impact on daily activities
  • navigate_next 20-item questionnaire that scores each item from “0” (not difficult at all) to “5” (unable to do)
  • navigate_next Real-time calculation of QBPDS Score based on the form responses
  • navigate_next Collect patient data and other sensitive healthcare data using our HIPAA compliant online assessment forms
  • navigate_next Compare the scores from the initial screening with that of the followup to track the progression of back pain related disability
  • navigate_next Easily create responsive forms that allow patients to complete their assessments on any device at any time

Collect responses from your patients

Patient ID 1004
Patient Name John W
Patient Email johnw@ymail.com
Patient Phone Number 0987654321
Doctor's Name Dr. Smith
Location New York
Select an answer for each statement below
1. Get out of bed Somewhat difficult
2. Sleep through the night Fairly difficult
3. Turn over in bed Very difficult
4. Ride in a car Unable to do
5. Stand up for 20-30 minutes Not difficult at all
6. Sit in a chair for several hours Minimally difficult
7. Climb one flight of stairs Somewhat difficult
8. Walk a few blocks (300-400 m) Fairly difficult
9. Walk several kilometres Very difficult
10. Reach up to high shelves Unable to do
11. Throw a ball Not difficult at all
12. Run one block (about 100m) Minimally difficult
13. Take food out of the refrigerator Somewhat difficult
14. Make your bed Fairly difficult
15. Put on socks (pantyhose) Very difficult
16. Bend over to clean the bathtub Unable to do
17. Move a chair Not difficult at all
18. Pull or push heavy doors Minimally difficult
19. Carry two bags of groceries Somewhat difficult
20. Lift and carry a heavy suitcase Fairly difficult
QBPDS score 75
  • navigate_next Pre-populate patient details such as patient id, name, email etc in the QBPDS assessment form before sharing it with the patients
  • navigate_next Send an email invitation with a secure link for patients to complete their QBPDS assessment form prior to their visit
  • navigate_next Allow patients to save their progress and complete their QBPDS assessment form at a later time without losing any responses
  • navigate_next Set up an email template for your QBPDS assessment and automatically send invitation emails to multiple patients with ease
  • navigate_next Send a confirmation email to the patients with their QBPDS score, diagnosis, next steps when they submit their QBPDS assessment

Track patient responses in Google Sheets

A B C D E
1 Name Question Answer Score Total Score
2 John W 1. Get out of bed Somewhat difficult 2 75
3 John W 2. Sleep through the night Fairly difficult 3 75
4 John W 3. Turn over in bed Very difficult 4 75
5 John W 4. Ride in a car Unable to do 5 75
6 John W 5. Stand up for 20-30 minutes Not difficult at all 0 75
7 John W 6. Sit in a chair for several hours Minimally difficult 1 75
8 John W 7. Climb one flight of stairs Somewhat difficult 2 75
9 John W 8. Walk a few blocks (300-400 m) Fairly difficult 3 75
10 John W 9. Walk several kilometres Very difficult 4 75
11 John W 10. Reach up to high shelves Unable to do 5 75
12 John W 11. Throw a ball Not difficult at all 0 75
13 John W 12. Run one block (about 100m) Minimally difficult 1 75
14 John W 13. Take food out of the refrigerator Somewhat difficult 2 75
15 John W 14. Make your bed Fairly difficult 3 75
16 John W 15. Put on socks (pantyhose) Very difficult 4 75
17 John W 16. Bend over to clean the bathtub Unable to do 5 75
18 John W 17. Move a chair Not difficult at all 0 75
19 John W 18. Pull or push heavy doors Minimally difficult 1 75
20 John W 19. Carry two bags of groceries Somewhat difficult 2 75
21 John W 20. Lift and carry a heavy suitcase Fairly difficult 3 75
  • navigate_next Export patient responses including the calculated QBPDS score to Google Sheets for easy record-keeping
  • navigate_next Export individual points for 20 items to Google Sheets for data manipulation and analysis for comprehensive insights
  • navigate_next Use pre-built reports to easily keep track of patient progress over time and monitor changes in their back pain related disability
  • navigate_next Receive a copy of the response and the calculated QBPDS score by email whenever a patient submits their QBPDS assessment
  • navigate_next Use data in Google Sheets to integrate with external EHR systems for seamless data transfer

HIPAA compliance

Patient ID: 1004
Patient Name: ******
Patient Email: ******
Patient Phone Number: ******
Doctor's Name: Dr. Smith
Location: New York
Select an answer for each statement below
1. Get out of bed:Somewhat difficult
2. Sleep through the night:Fairly difficult
3. Turn over in bed:Very difficult
4. Ride in a car:Unable to do
5. Stand up for 20-30 minutes:Not difficult at all
6. Sit in a chair for several hours:Minimally difficult
7. Climb one flight of stairs:Somewhat difficult
8. Walk a few blocks (300-400 m):Fairly difficult
9. Walk several kilometres:Very difficult
10. Reach up to high shelves:Unable to do
11. Throw a ball:Not difficult at all
12. Run one block (about 100m):Minimally difficult
13. Take food out of the refrigerator:Somewhat difficult
14. Make your bed:Fairly difficult
15. Put on socks (pantyhose):Very difficult
16. Bend over to clean the bathtub:Unable to do
17. Move a chair:Not difficult at all
18. Pull or push heavy doors:Minimally difficult
19. Carry two bags of groceries:Somewhat difficult
20. Lift and carry a heavy suitcase:Fairly difficult
QBPDS score: 75
QBPDS score: 75
  • navigate_next Create a HIPAA compliant QBPDS assessment form to safely collect, store and access patient responses
  • navigate_next Mark fields as Protected Health Information (PHI) to secure sensitive patient data and limit access to PHI
  • navigate_next Automatically mask PHI fields when exporting QBPDS form responses to Google Sheets and sending them on email
  • navigate_next Prepopulate patient details in QBPDS assessments by creating secure prefill links without exposing PHI
  • navigate_next Limit access to patient data only for authorized personnel and minimize the risk of data breaches

These reviews are reproduced without modification from Google Workspace Marketplace.

July 27, 2023

5 stars

I am 100% a fan of this company. We use HIPAA compliant Google Forms and needed a way to collect signatures, the industry standard company is TOO expensive. I started using FormEsign and it worked perfectly. It lacked the ability to provide a pdf copy of the form after signature. This company worked with me help their product evolve into something that could benefit all future clients AND the end user. The team was polite, professional, kind, enthusiastic, and willing to make a change. This earned my loyalty. I will sing their praises. Good work, and thank you!

— Royal Bush

July 23, 2023

5 stars

I am not tech savvy. I chose formesign to help create registration links for clients. Vipid has been great in assisting me. He goes above and beyond. My company now has moved from the stone age to modern age through the ability to use this feature. Of the many features I am impressed with, the ability to update a form without needing to regenerate a link is amazing. I often make mistakes and that ability allows me to fix mistakes without needing to change everything. Thank you!!!

— Sol Evans

February 16, 2024

1 stars

Does not work

— Myles Sicuro

October 30, 2023

5 stars

We needed a way to create forms with e-signatures and this app made it very easy. Support is also very quick and always helpful. Cannot recommend enough!

— Chris Henesy

July 12, 2023

5 stars

It very friendly to used. I love it. For my case multiple signature needed. it's supporting

— Senthil Kumar

November 27, 2023

5 stars

Yeah this is good for all

— luqman khan

July 10, 2023

5 stars

We were looking for a way to have a signature option in our form. Formesign addon allowed us to collect signatures for the acknowledgment and consent forms. It was simple and easy to setup. Very useful addon for google forms.

— Joan S

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