Back Support Belt

- Questionnaire



1. You find yourself in which situation?
I can lift heavy objects without any extra pain
I can lift heavy objects but it gives extra back pain
2. When heavy lifting or carrying would you be willing to
wear a back support belt?
Yes
No*
*If the second answer is chosen, the questionnaire stops here.
3. What is your main reason for wearing a back support
belt?
Pain Prevention
Pain Treatment
4. According to their notoriety, rank the following back belt
brands (1- the best known, 3- the least known)
Dr. Levines Back Belt
Dr. Med Back Support
Mueller Adjustable Back Support

5. What is the minimum amount you would be willing to pay
for a back support belt?
....................
6. What is the maximum amount you would be willing to pay
for a back support belt?
.....................
7. What extra features would you want from a back support
belt to have?
Non-sweaty, no rash fabric
Vents excess heat
Lightweight and breathable
Magnet band incorporated
Other..

8. Through which channel would you like to receive more
information about the Back Belt product?
Television
Radio
Newspaper
Internet
Doctors

9. How much a promotional campain influences you in
acquiring this kind of product?

Very much Much Somehow Very little At all
5 4 3 2 1


10. On a scale from 1 to 9, what do you think that are the benefits of wearing a back support belt? (1- not effective,
5- somehow effective, 9 very effective)

Action Not
effective
Somehow
effective
Very
effective
Lowering back
pain
1 2 3 4 5 6 7 8 9
Improving
posture
1 2 3 4 5 6 7 8 9
Preventing back
problems
1 2 3 4 5 6 7 8 9
Improving
movement
1 2 3 4 5 6 7 8 9




11. Related to back pain, round the number that indicates the degree of pain you feel when one of the following
actions happens, taking into consideration that 1 is no pain and 9 is very severe pain.

Action No pain Pain Very
severe
pain
Walking 1 2 3 4 5 6 7 8 9
Sleeping 1 2 3 4 5 6 7 8 9
Sitting on a chair 1 2 3 4 5 6 7 8 9
Moving easy
things
1 2 3 4 5 6 7 8 9
Moving heavy
things
1 2 3 4 5 6 7 8 9
Carrying easy
things
1 2 3 4 5 6 7 8 9
Carrying hard
things
1 2 3 4 5 6 7 8 9
Driving 1 2 3 4 5 6 7 8 9
Running 1 2 3 4 5 6 7 8 9
Climbing stairs 1 2 3 4 5 6 7 8 9


12. On a scale from 1 to 9, how much do you think the back support system will affect you on the following items?
(1- not at all, 5- somehow, 9 a lot)

Action Not at all Somehow A lot
Self-esteem 1 2 3 4 5 6 7 8 9
Perception of
others
1 2 3 4 5 6 7 8 9
Clothes selection 1 2 3 4 5 6 7 8 9
Overall cosmetic
appearance
1 2 3 4 5 6 7 8 9
Comfort 1 2 3 4 5 6 7 8 9

13. How much you would be willing to wear a back support belt?

Time interval Willingness Yes/No
1 hour/day
4 hours/day
8 hours/day
12 hours/day
24 hours/day

14.Related to surgery, on a scale from 1 to 10, how much fear do you feel when it comes to surgery? (1- no fear, 5
little fear, 9 strong fear)

No fear Little fear Strong fear
1 2 3 4 5 6 7 8 9

15. On a scale from 1 to 9, how much you would be bothered if you had to wear the belt in the following time
intervals?

Action Not at all Somehow A lot
1 hour/day 1 2 3 4 5 6 7 8 9
4 hours/day 1 2 3 4 5 6 7 8 9
8 hours/day 1 2 3 4 5 6 7 8 9
12 hours/day 1 2 3 4 5 6 7 8 9
24 hours/day 1 2 3 4 5 6 7 8 9



16. What other concerns do you have when it comes to wearing or purchasing a back support belt? Please add on
yourself at least two more concerns.
Action Not at all Somehow A lot
Discomfort when
wearing
1 2 3 4 5 6 7 8 9
It could be
unuseful
1 2 3 4 5 6 7 8 9
Price 1 2 3 4 5 6 7 8 9
Fast deterioration 1 2 3 4 5 6 7 8 9
.. 1 2 3 4 5 6 7 8 9
.. 1 2 3 4 5 6 7 8 9
.. 1 2 3 4 5 6 7 8 9
.. 1 2 3 4 5 6 7 8 9

Age:.

Gender: Male Female

Professional occupation: ..................................................................

Hobbies:.
QUALITY OF LIFE SCALE (QOL)

Please read each item and circle the number that best describes how satisfied you are at this time. Please answer each item
even if you do not currently participate in an activity or have a relationship. You can be satisfied or dissatisfied with not
doing the activity or having the relationship.


Delighted Pleased Mostly
satisfied
Mixed Mostly
dissatisfied
Unhappy Terrible
1
Material comforts home, food,
conveniences,
financial security
7

6 5 4 3 2 1
2
Health - being physically fit and
vigorous
7 6 5 4 3 2 1
3
Relationships with parents, siblings &
other relatives- communicating,
visiting, helping
7 6 5 4 3 2 1
4
Having and rearing children 7 6 5 4 3 2 1
5
Close relationships with spouse or
significant other
7 6 5 4 3 2 1
6
Close friends 7 6 5 4 3 2 1
7
Helping and encouraging others,
volunteering, giving advice
7 6 5 4 3 2 1
8
Participating in organizations and
public affairs
7 6 5 4 3 2 1
9
Learning- attending school, improving
understanding, getting additional
knowledge
7 6 5 4 3 2 1
10
Understanding yourself - knowing
your assets and limitations - knowing
what life is about
7 6 5 4 3 2 1
11
Work - job or in home 7 6 5 4 3 2 1
12
Expressing yourself creatively 7 6 5 4 3 2 1
13
Socializing - meeting other people,
doing things, parties, etc
7 6 5 4 3 2 1
14
Reading, listening to music, or
observing entertainment
7 6 5 4 3 2 1
15
Participating in active recreation 7 6 5 4 3 2 1
16
Independence, doing for yourself 7 6 5 4 3 2 1