Low Back Pain Disability Index Questionnaire Template
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1Low Back Pain Disability Index (Revised Oswestry)
Patient Name: ___________________________________ Date: ____________________________________
This questionnaire has been designed to give the doctor information as to how your back pain has affected your
ability to manage in everyday life. Please answer every section and mark in each section only ONE box which
applies to you. We realize you may consider that two of the statements in any one section relate to you, but
please just mark the box which most closely describes your problem.
SECTION 1—PAIN INTENSITY
SECTION 6—STANDING
The pain comes and goes & is very mild
I can stand as long as I want without pain
□
The pain is mild & does not vary much
I have some pain on standing but it does not increase with time
□
The pain comes and goes & 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 ½ hour without increasing pain
□
The pain comes and goes and is very severe
□
I cannot stand for longer than 10 minutes without increasing pain
The pain is severe and does not vary much
□
I avoid standing because it increases the pain straight away
SECTION 2—PERSONAL CARE
SECTION 7—SLEEPING
I would not have to change my way of washing or dressing in
□
I have no trouble sleeping
order to avoid pain
My sleep is slightly disturbed (less than 1 hr. sleepless)
I do not normally change my way of washing or dressing even
□
My sleep is mildly disturbed (1-2 hrs. sleepless)
though it causes some pain
My sleep is moderately disturbed (2-3 hrs. sleepless)
Washing & dressing increase the pain but I manage not to change
□
My sleep is greatly disturbed (3-4 hrs. sleepless)
my way of doing it
My sleep is completely disturbed (5-7 hrs. sleepless
Washing & dressing increase the pain & I find it necessary to
□
change my way of doing it
SECTION 8—SOCIAL LIFE
Because of the pain I am unable to do some washing & dressing
□
My social life is normal & gives me no pain
without help
My social life is normal but increases the degree of pain
Because of the pain I an unable to do any washing & dressing
□
Pain has no significant effect on my social life apart from
without help
limiting my more energetic interests e.g. dancing
Pain has restricted my social life & I don’t go out very often
SECTION 3—LIFTING
Pain has restricted my social life to my home
I can lift heavy weights without extra pain
□
I have hardly any social life because of the pain
I can lift heavy weights but it causes extra pain
□
Pain prevents me from lifting heavy weights off the floor, I can
□
SECTION 9—TRAVELLING
manage if they are conveniently positioned ie: on a table
I get no pain while travelling
Pain prevents me from lifting heavy weights but I can manage
□
I get some pain while travelling, but none of my usual forms of
light to medium weights if they are conveniently positioned
travel make it worse
I can lift very light weights
□
I get extra pain while travelling, but it doesn’t compel me to seek
I cannot lift or carry anything at all
□
alternative forms of travel
I get extra pain while traveling which compels me to seek
SECTION 4—WALKING
alternative forms of travel
I have no pain when I walk
□
Pain restricts all forms of travel
I have some pain on walking but it doesn’t increase with distance
□
Pain prevents all forms of travel except that done lying down
I cannot walk more than one mile without increasing pain
□
I cannot walk more than ½ mile without increasing pain
SECTION 10—CHANGING DEGREE OF PAIN
□
My pain is rapidly getting better
I cannot walk more than ¼ mile without increasing pain
□
□
My pain fluctuates but overall is definitely getting better
I cannot walk at all without increasing pain
□
□
My pain seems to be getting better but improvement is slow at
□
present
SECTION 5—SITTING
My pain is neither getting better nor worse
I can sit in any chair as long as I like
□
□
My pain is gradually worsening
I can only sit in my favourite chair as long as I like
□
□
My pain is rapidly worsening
Pain prevents me from sitting more than one hour
□
□
Pain prevents me from sitting more than ½ hour
□
Pain prevents me from sitting more than 10 minutes
□
I avoid sitting because it increases pain straight away
□
Pain Severity Scale: Rate the severity of your pain by circling one box of the following scale.
No Pain
Excruciating Pain
0
1
2
3
4
5
6
7
8
9
10
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0 votes
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