Keele STarT Back Screening Tool
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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
  • navigate_next Prebuilt template with scoring to assess the presence and severity of low back pain
  • navigate_next 9-item questionnaire that scores each item as “0” (disagree) to “1” (agree)
  • navigate_next Real-time calculation of overall score and distress score based on the form responses
  • navigate_next Stratify patients into low, medium or high risk categories for poor outcome based on their scores
  • navigate_next Collect patient data and other sensitive healthcare data using our HIPAA compliant online assessment forms
  • 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
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
  • navigate_next Pre-populate patient details such as patient id, name, email etc in the Keele STarT Back Screening Tool before sharing it with the patients
  • navigate_next Send an email invitation with a secure link for patients to complete their assessment form prior to their visit
  • navigate_next Allow patients to save their progress and complete their assessment form at a later time without losing any responses
  • navigate_next Set up an email template for your assessment and automatically send invitation emails to multiple patients with ease
  • navigate_next 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
  • navigate_next Export patient responses including the calculated overall score, distress score and risk of poor outcome to Google Sheets for easy record-keeping
  • navigate_next Export individual points for each item 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 symptoms
  • navigate_next Receive a copy of the response and the calculated scores by email whenever a patient submits their 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
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
  • navigate_next Create a HIPAA compliant Keele STarT Back Screening Tool 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 form responses to Google Sheets and sending them on email
  • navigate_next Prepopulate patient details in 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 31, 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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