Oswestry Low Back Pain Disability Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by checking ONE box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem.

Full Name *

Date of Birth *

YYYY

Section 1 – Pain intensity

0) I can tolerate the pain I have without having to use pain medication

1) The pain is bad, but I can manage without having to take pain medication

2) The pain is moderate at the moment

3) The pain is fairly severe at the moment

4) The pain is very severe at the moment

5) The pain is the worst imaginable at the moment

Clear selection

Section 2 – Personal care (washing, dressing etc)

0) I can look after myself normally without causing extra pain

1) I can look after myself normally but it causes extra pain

2) It is painful to look after myself and I am slow and careful

3) It is painful to look after myself and I am slow and careful

4) I need help every day in most aspects of self care

5) I do not get dressed wash with difficulty and stay in bed

Clear selection

Section 3 - Lifting

0) I can lift heavy weights without extra pain

1) I can lift heavy weights, but it causes extra pain

2) Pain prevents me lifting heavy weights off the floor but I can manage if they are conveniently placed eg. on a table

3) Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned

4) I can only lift very light weights

5) I cannot lift or carry anything

Clear selection

Section 4 - Walking

0) Pain does not prevent me walking any distance

1) Pain prevents me from walking more than 1 mile

2) Pain prevents me from walking more than 1/2 mile

3) Pain prevents me from walking more than 100 yards

4) I can only walk using a stick/cane or crutches

5) I am in bed most of the time and have to crawl to the toilet

Clear selection

Section 5 - Sitting

0) I can sit in any chair as long as I like

1) I can only sit in my favourite chair as long as I like

2) Pain prevents me sitting more than one hour

3) Pain prevents me from sitting more than 30 minutes

4) Pain prevents me from sitting more than 10 minutes

5) Pain prevents me from sitting at all

Clear selection

Section 6 - Standing *

0) I can stand as long as I want without increased pain

1) I can stand as long as I want, but it increases my pain

2) Pain prevents me from standing for more than 1 hour

3) Pain prevents me from standing for more than 30 minutes

4) Pain prevents me from standing for more than 10 minutes

5) Pain prevents me from standing at all

Section 7 - Sleeping *

0) Pain does not prevent me from sleeping well

1) I can sleep well only by using pain medication

2) Even when I take medication, I sleep less than 6 hours

3) Even when I take medication, I sleep less than 4 hours

4) Even when I take medication, I sleep less than 2 hours

5) Pain prevents me from sleeping at all

Section 8 - Social Life *

0) My social life is normal and gives me no extra pain

1) My social life is normal but increases the degree of pain

2) Pain has no significant effect on my social l ife apart from limiting my more energetic interests e.g. sport

3) Pain has restricted my social life and I do not go out as often

4) Pain has restricted my social life to my home

5) I have no social life because of pain

Section 9 - Traveling

0) I can travel anywhere without pain

1) I can travel anywhere but it increases my pain

2) My pain restricts my travel over 2 hours

3) My pain restricts my travel over 1 hour

4) My pain restricts my travel to short necessary journeys under 30 minutes

5) My pain prevents all travel except for visits to the physician/therapist or hospital

Clear selection

Section 10 - Employment/Homemaking *

0) My normal homemaking/job activities do not cause pain

1) My normal homemaking/job activities increase my pain, but I can still perform all that is required of me

2) I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (e.g., lifting, vacuuming)

3) Pain prevents me from doing anything but light duties

4) Pain prevents me from doing even light duties

5) Pain prevents me from performing any job or homemaking chores

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of kirbachphysicaltherapy.com. Report Abuse

Forms