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LAMPIRAN

Lampiran I

Visual Analogue Scale (VAS)

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Lampiran II

Owestry Low Back Pain Questionare

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Lampiran 3

Informed Consent

PERNYATAAN PERSETUJUAN SEBAGAI RESPONDEN

(INFORMED CONSENT)

Setelah mendapat informasi yang jelas tentang tujuan dan manfaat dari penelitian
ini, maka saya :

Nama : ................................................................

TTL : ................................................................

Umur : ................................................................

Jenis Kelamin : ................................................................

Alamat : ................................................................

No. Telp/HP : .................................................................

Menyatakan bersedia untuk mengikuti penelitian tentang :

PENATALAKSANAAN FISIOTERAPI PADA KASUS LOW BACK PAIN ET

CAUSA LUMBAR SPONDYLOSIS DENGAN MODALITAS TRANSCUTANEUS
ELECTRICAL NERVE STIMULATION (TENS), MAITLAND MOBILIZATION
DAN LUMBAR STABILIZATION, secara suka rela setelah mendapat penjelasan
tentang tujuan dan manfaat dari penelitian tersebut.

Pelaksana Penelitian Surabaya, ....... 2019

Responden

( ................................) ( .............................. )

Saksi

( ............................ )