Monroe Community College - State University of New York


prospective



Dental Studies
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WORKSHEET 15-A:

spine

Back care evaluation survey.


Select the word that best represents your current lifestyle in response to the statement.

  1. I engage in a formal exercise routine.
Always: Regularly: Sometimes: Rarely: Never:
  1. I am in the acceptable range for body fat percentage.
Always: Regularly: Sometimes: Rarely: Never:
  1. I stand in a stationary position for long periods of time.
Always: Regularly: Sometimes: Rarely: Never:
  1. I sit in a stationary position for long periods of time.
Always: Regularly: Sometimes: Rarely: Never:
  1. I sit with both feet flat on the floor.
Always: Regularly: Sometimes: Rarely: Never:
  1. I sit with my back up against the backrest.
Always: Regularly: Sometimes: Rarely: Never:
  1. When I sit, I reach, stretch, and twist to do my work.
Always: Regularly: Sometimes: Rarely: Never:
  1. When I drive, I move the seat back as far as possible.
Always: Regularly: Sometimes: Rarely: Never:
  1. When I carry something, I carry it as close to the body as possible.
Always: Regularly: Sometimes: Rarely: Never:
  1. When I carry something, I balance it on both sides on my body.
Always: Regularly: Sometimes: Rarely: Never:
  1. When I lift something, Iuse my legs.
Always: Regularly: Sometimes: Rarely: Never:
  1. When I lift something, I twist and turn while doing it.
Always: Regularly: Sometimes: Rarely: Never:
  1. My job requires me to lift heavy objects.
Always: Regularly: Sometimes: Rarely: Never:
  1. My job requires me to lift lighter objects continually.
Always: Regularly: Sometimes: Rarely: Never:
  1. I sleep on my stomach.
Always: Regularly: Sometimes: Rarely: Never:
  1. I sleep on my back.
Always: Regularly: Sometimes: Rarely: Never:
  1. I sleep on a very soft mattress/surface.
Always: Regularly: Sometimes: Rarely: Never:
  1. My job requires me to do a lot of pushing.
Always: Regularly: Sometimes: Rarely: Never:
  1. My job requires me to do a lot of pulling.
Always: Regularly: Sometimes: Rarely: Never:
  1. I am conscious of my posture.
Always: Regularly: Sometimes: Rarely: Never:
  1. I eat a balanced mixed diet.
Always: Regularly: Sometimes: Rarely: Never:
  1. My age is
20 - 29: 30 -39: 40 - 49: 50 - 59:
60 - 69:



Basic Risk Evaluation Chart

Score
Risk
0 - 10
Low Risk
11 - 35
Below Average Risk
36 - 75
Average Risk
76 - 100
Above Average Risk
101 - 110
High Risk

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Go Back To Main Menu Go To Worksheet 16-A
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MCC-B770

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MCC-B770