Modified Oswestry Low Back Pain Disability Questionnaire Template printable pdf download

Modified Oswestry Low Back Pain Disability Questionnaire

This questionnaire has been designed to give your therapist information as to how your back pain has affected

your ability to manage in everyday life. Please answer every question by placing a mark in the one box that

best describes your condition today. We realize you may feel that two of the statements may describe your

condition, but please mark only the box that most closely describes your current condition.

Pain Intensity

Sitting

I can tolerate the pain I have without having to use

I can sit in any chair as long as I like.

pain medication.

I can only sit in my favorite chair as long as I like.

The pain is bad, but I can manage without having

Pain prevents me from sitting for more than 1 hour.

to take pain medication.

Pain prevents me from sitting for more than

Pain medication provides me with complete relief

1/2 hour.

Pain prevents me from sitting for more than

from pain.

Pain medication provides me with moderate relief

10 minutes.

from pain.

Pain prevents me from sitting at all.

Pain medication provides me with little relief

from pain.

Standing

Pain medication has no effect on my pain.

I can stand as long as I want without increased pain.

I can stand as long as I want, but it increases

Personal Care (e.g., Washing, Dressing)

my pain.

I can take care of myself normally without causing

Pain prevents me from standing for more than

increased pain.

1 hour.

I can take care of myself normally, but it increases

Pain prevents me from standing for more than

my pain.

1/2 hour.

It is painful to take care of myself, and I am slow

Pain prevents me from standing for more than

and careful.

10 minutes.

I need help, but I am able to manage most of my

Pain prevents me from standing at all.

personal care.

I need help every day in most aspects of my care.

Sleeping

I do not get dressed, I wash with difficulty, and I

Pain does not prevent me from sleeping well.

stay in bed.

I can sleep well only by using pain medication.

Even when I take medication, I sleep less than

Lifting

6 hours.

I can lift heavy weights without increased pain.

Even when I take medication, I sleep less than

I can lift heavy weights, but it causes increased pain.

4 hours.

Pain prevents me from lifting heavy weights off

Even when I take medication, I sleep less than

the floor, but I can manage if the weights are

2 hours.

conveniently positioned (e.g., on a table).

Pain prevents me from sleeping at all.

Pain prevents me from lifting heavy weights, but

I can manage light to medium weights if they are

Social Life

conveniently positioned.

My social life is normal and does not increase

I can lift only very light weights.

my pain.

I cannot lift or carry anything at all.

My social life is normal, but it increases my level

of pain.

Walking

Pain prevents me from participating in more

Pain does not prevent me from walking any distance.

energetic activities (e.g., sports, dancing).

Pain prevents me from walking more than 1 mile.

Pain prevents me from going out very often.

(1 mile = 1.6 km).

Pain has restricted my social life to my home.

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

I have hardly any social life because of my pain.

Pain prevents me from walking more than 1/4 mile.

I can walk only with crutches or a cane.

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

the toilet.

Please complete questionnaire on other side.

Modified Oswestry Low Back Pain Disability Questionnaire Template

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