Oswestry Disability Index - Foundational Concepts

Personal Information & History

Name

First Last

Today's Date

Who is your therapist?

I have “Chronic Pain” or pain that has bothered me for 3 months or more*

Yes
No

Please check one of the following in relation where you are timewise in your current condition*

I have not yet had surgery for this issue
After Surgery 6 weeks
After Surgery 3 Months
After Surgery 6 Months
After Surgery 1 year
After Surgery 2 years

Questionnaire

When answering the following question you may feel that more than one of the statements relates to you, but please check the option that best describes your problem at this time.

1. Pain Intensity*

I can tolerate the pain I have without having to use painkillers. [0 points]
The pain is bad but I manage without taking painkillers. [1 point]
Painkillers give complete relief from pain. [2 points]
Painkillers give moderate relief from pain. [3 points]
Painkillers give very little relief from pain. [4 points]
Painkillers have no effect on the pain and I do not use them. [5 points]

2. Personal Care*

I can look after myself normally without causing extra pain. [0 points]
I can look after myself normally but it causes extra pain. [1 point]
It is painful to look after myself and I am slow and careful. [2 points]
I need some help but manage most of my personal care. [3 points]
I need help every day in most aspects of self care. [4 points]
I do not get dressed wash with difficulty and stay in bed. [5 points]

3. Lifting*

I can lift heavy weights without extra pain. [0 points]
I can lift heavy weights but it gives extra pain. [1 point]
Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned for example on a table. [2 points]
Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. [3 points]
I can lift only very light weights. [4 points]
I cannot lift or carry anything at all. [5 points]

4. Walking*

Pain does not prevent me walking any distance. [0 points]
Pain prevents me walking more than 1 mile. [1 point]
Pain prevents me walking more than 0.5 miles. [2 points]
Pain prevents me walking more than 0.25 miles. [3 points]
I can only walk using a stick or crutches. [4 points]
I am in bed most of the time and have to crawl to the toilet. [5 points]

5. Sitting*

I can sit in any chair as long as I like. [0 points]
I can only sit in my favorite chair as long as I like. [1 point]
Pain prevents me sitting more than 1 hour. [2 points]
Pain prevents me from sitting more than 0.5 hours. [3 points]
Pain prevents me from sitting more than 10 minutes. [4 points]
Pain prevents me from sitting at all. [5 points]

6. Standing*

I can stand as long as I want without extra pain. [0 points]
I can stand as long as I want but it gives me extra pain. [1 point]
Pain prevents me from standing for more than 1 hour. [2 points]
Pain prevents me from standing for more than 30 minutes. [3 points]
Pain prevents me from standing for more than 10 minutes. [4 points]
Pain prevents me from standing at all. [5 points]

7. Sleeping*

Pain does not prevent me from sleeping well. [0 points]
I can sleep well only by using tablets. [1 point]
Even when I take tablets I have less than 6 hours sleep. [2 points]
Even when I take tablets I have less than 4 hours sleep. [3 points]
Even when I take tablets I have less than 2 hours of sleep. [4 points]
Pain prevents me from sleeping at all. [5 points]

8. Sex Life*

My sex life is normal and causes no extra pain. [0 points]
My sex life is normal but causes some extra pain. [1 point]
My sex life is nearly normal but is very painful. [2 points]
My sex life is severely restricted by pain. [3 points]
My sex life is nearly absent because of pain. [4 points]
Pain prevents any sex life at all. [5 points]

9. Social Life*

My social life is normal and gives me no extra pain. [0 points]
My social life is normal but increases the degree of pain. [1 point]
Pain has no significant effect on my social life apart from limiting energetic interests such as dancing. [2 points]
Pain has restricted my social life and I do not go out as often. [3 points]
Pain has restricted my social life to my home. [4 points]
I have no social life because of pain. [5 points]

10. Traveling*

I can travel anywhere without extra pain. [0 points]
I can travel anywhere but it gives me extra pain. [1 point]
Pain is bad but I manage journeys over 2 hours. [2 points]
Pain restricts me to journeys of less than 1 hour. [3 points]
Pain restricts me to short necessary journeys under 30 minutes. [4 points]
Pain prevents me from traveling except to the doctor or hospital. [5 points]

Oswestry Lower Back Pain Disability Index

Personal Information & History

Questionnaire