Neck Pain And Disability Index Questionnaire Template (Page 2 of 2) in pdf

LOW BACK PAIN AND DISABILITY INDEX (REVISED OSWESTRY)

Patient Name: ________________________________________________

Date: ______/______/______

Please read instructions carefully.

This questionnaire has been designed to give the doctor information as to how your low back pain has affected your ability to manage everyday life.

Please read all statements in each section and mark the box which most closely describes your problem.

SECTION 1 - PAIN INTENSITY

SECTION 6 - STANDING

The pain comes and goes and is very mild.

I can stand as long as I want without pain.

The pain is mild and does not vary much.

I have some pain on standing but it does not increase with time.

The pain comes and goes and is moderate.

I cannot stand for longer than one hour without increasing pain.

The pain is moderate and does not vary much.

I cannot stand for longer than 1/2 hour without increasing pain.

The pain comes and goes and is very severe.

I cannot stand longer than 10 minutes without increasing pain.

The pain is severe and does not vary much.

I avoid standing because it increases the pain.

SECTION 2 - PERSONAL CARE

SECTION 7 - SLEEPING

I do not have to change my way of washing or dressing to avoid pain.

I get no pain in bed.

I do not normally change my way of washing or dressing even though

I get pain in bed but it does not prevent me from sleeping well.

it causes some pain.

Pain reduces my normal sleep by 1/4 each night.

Washing and dressing increases the pain but I manage not to change

Pain reduces my normal sleep by 1/2 each night.

my way of doing it.

Pain reduces my normal sleep by 3/4 each night.

Washing and dressing increases the pain and I find it necessary to

Pain prevents me from sleeping at all.

change my way of doing it.

Because of the pain, I am unable to do some washing and dressing

SECTION 8 - SOCIAL LIFE

without help.

Because of the pain, I am unable to do any washing or dressing

My social life is normal and gives me no pain.

without help.

My social life is normal but increases the degree of pain.

My social life is unaffected by pain apart form limiting more

SECTION 3 - LIFTING

energetic interests.

Pain has restricted my social life and I do not go out very often.

I can lift heavy objects without any extra pain.

Pain has restricted my social life to my home.

I can lift heavy objects, but it gives extra pain.

I have hardly any social life because of the pain.

Pain prevents me from lifting heavy objects off the floor.

Pain prevents me from lifting heavy objects off the floor but I can

SECTION 9 - DRIVING / RIDING IN CAR, ETC.

manage if they are conveniently positioned on a table.

Pain prevents me from lifting heavy objects but I can manage

I get no pain while traveling.

light to medium objects.

I get some pain while traveling but none of my usual forms of travel

I can only lift very light objects at the most.

make it any worse.

I get extra pain while traveling but it does not compel me to seek

SECTION 4 - WALKING

alternate forms of travel.

I get extra pain while traveling which compels me to seek alternate

I have no pain on walking.

forms of travel.

I have some pain but it does not increase with distance.

Pain restricts all forms of travel.

I cannot walk more than one mile without increasing pain.

Pain prevents all forms of travel except that done lying down.

I cannot walk more than 1/2 mile without increasing pain.

I cannot walk more than 1/4 mile without increasing pain.

SECTION 10 - CHANGING DEGREE OF PAIN

I cannot walk at all without increasing pain.

My pain is rapidly getting better.

SECTION 5 - SITTING

My pain fluctuates but overall is definitely getting better.

My pain seems to be getting better but improvement is slow at

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

present.

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

My pain is neither getting better or worse.

Pain prevents me from sitting more than one hour.

My pain is gradually worsening.

Pain prevents me from sitting more than half an hour.

My pain is rapidly worsening.

Pain prevents me from sitting more than 10 minutes.

I avoid sitting because it increases pain.

LOW BACK PAIN SCALE

Rate the severity of your Low Back Pain by indicating on the following scale.

Absence

I-----------------------------------------------------------------I

Extreme

Neck Pain And Disability Index Questionnaire Template Page 2

Related Articles

Related forms

Related Categories