Use our readymade template to create your Keele STarT Back Screening Tool for low back pain
Create your care assessments
| Overall score | Distress score | Risk of poor outcome |
|---|---|---|
| 0-3 | 0-3 | Low |
| 4-9 | 0-3 | Medium |
| 4-9 | 4-9 | High |
- Prebuilt template with scoring to assess the presence and severity of low back pain
- 9-item questionnaire that scores each item as “0” (disagree) to “1” (agree)
- Real-time calculation of overall score and distress score based on the form responses
- Stratify patients into low, medium or high risk categories for poor outcome based on their scores
- Collect patient data and other sensitive healthcare data using our HIPAA compliant online assessment forms
- 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 |
| 1. My back pain has spread down my leg(s) at some time in the last 2 weeks | Agree |
| 2. I have had pain in the shoulder or neck at some time in the last 2 weeks | Agree |
| 3. I have only walked short distances because of my back pain | Agree |
| 4. In the last 2 weeks, I have dressed more slowly than usual because of back pain | Agree |
| 5. It’s not really safe for a person with a condition like mine to be physically active | Agree |
| 6. Worrying thoughts have been going through my mind a lot of the time | Agree |
| 7. I feel that my back pain is terrible and it’s never going to get any better | Agree |
| 8. In general I have not enjoyed all the things I used to enjoy | Agree |
| 9. Overall, how bothersome has your back pain been in the last 2 weeks? | Very much |
| Overall score | 9 |
| Distress score | 4 |
| Risk of poor outcome | High |
- Pre-populate patient details such as patient id, name, email etc in the Keele STarT Back Screening Tool before sharing it with the patients
- Send an email invitation with a secure link for patients to complete their assessment form prior to their visit
- Allow patients to save their progress and complete their assessment form at a later time without losing any responses
- Set up an email template for your assessment and automatically send invitation emails to multiple patients with ease
- Send a confirmation email to the patients with their overall score, distress score, risk of poor outcome when they submit their assessment
Track patient responses in Google Sheets
| A | B | C | D | E | |
|---|---|---|---|---|---|
| 1 | Name | Question | Answer | Score | Total Score |
| 2 | John W | 1. My back pain has spread down my leg(s) at some time in the last 2 weeks | Agree | 1 | 9 |
| 3 | John W | 2. I have had pain in the shoulder or neck at some time in the last 2 weeks | Agree | 1 | 9 |
| 4 | John W | 3. I have only walked short distances because of my back pain | Agree | 1 | 9 |
| 5 | John W | 4. In the last 2 weeks, I have dressed more slowly than usual because of back pain | Agree | 1 | 9 |
| 6 | John W | 5. It’s not really safe for a person with a condition like mine to be physically active | Agree | 1 | 9 |
| 7 | John W | 6. Worrying thoughts have been going through my mind a lot of the time | Agree | 1 | 9 |
| 8 | John W | 7. I feel that my back pain is terrible and it’s never going to get any better | Agree | 1 | 9 |
| 9 | John W | 8. In general I have not enjoyed all the things I used to enjoy | Agree | 1 | 9 |
| 10 | John W | 9. Overall, how bothersome has your back pain been in the last 2 weeks? | Very much | 1 | 9 |
- Export patient responses including the calculated overall score, distress score and risk of poor outcome to Google Sheets for easy record-keeping
- Export individual points for each item to Google Sheets for data manipulation and analysis for comprehensive insights
- Use pre-built reports to easily keep track of patient progress over time and monitor changes in their back pain symptoms
- Receive a copy of the response and the calculated scores by email whenever a patient submits their assessment
- 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 |
| 1. My back pain has spread down my leg(s) at some time in the last 2 weeks: | Agree |
| 2. I have had pain in the shoulder or neck at some time in the last 2 weeks: | Agree |
| 3. I have only walked short distances because of my back pain: | Agree |
| 4. In the last 2 weeks, I have dressed more slowly than usual because of back pain : | Agree |
| 5. It’s not really safe for a person with a condition like mine to be physically active : | Agree |
| 6. Worrying thoughts have been going through my mind a lot of the time : | Agree |
| 7. I feel that my back pain is terrible and it’s never going to get any better: | Agree |
| 8. In general I have not enjoyed all the things I used to enjoy: | Agree |
| 9. Overall, how bothersome has your back pain been in the last 2 weeks?: | Very much |
| Overall score: | 9 |
| Distress score: | 4 |
| Risk of poor outcome : | High |
| Overall score: | 9 |
| Risk of poor outcome : | High |
- Create a HIPAA compliant Keele STarT Back Screening Tool to safely collect, store and access patient responses
- Mark fields as Protected Health Information (PHI) to secure sensitive patient data and limit access to PHI
- Automatically mask PHI fields when exporting form responses to Google Sheets and sending them on email
- Prepopulate patient details in assessments by creating secure prefill links without exposing PHI
- 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.
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