Oswestry Disability Index printable pdf download

OSWESTRY DISABILITY INDEX

Name:_________________________________

Date:__________________________________

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.

Section 1: Pain Intensity

Section 6: Standing

I have no pain at the moment

I can stand as long as I want without extra pain

The pain is very mild at the moment

I can stand as long as I want but it gives me extra pain

The pain is moderate at the moment

Pain prevents me from standing for more than 1 hour

The pain is fairly severe at the moment

Pain prevents me from standing for more than 30 minutes

The pain is very severe at the moment

Pain prevents me from standing for more than 10 minutes

The pain is the worst imaginable at the moment

Pain prevents me from standing at all

Section 2: Personal Care (Washing, Dressing, etc.)

Section 7: Sleeping

I can look after myself normally without causing extra pain

My sleep is never disturbed by pain

I can look after myself normally but it causes extra pain

My sleep is occasionally disturbed by pain

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

Because of pain I have less than 6 hours sleep

I need some help but can manage most of my personal care

Because of pain I have less than 4 hours sleep

I need help every day in most aspects of self care

Because of pain I have less than 2 hours sleep

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

Pain prevents me from sleeping at all

Section 3: Lifting

Section 8: Social Life

I can lift heavy weights without extra pain

My social life is normal and gives me no extra pain

I can lift heavy weights but it gives me extra pain

My social life is normal but increases the degree of pain

Pain prevents me lifting heavy weights off the floor but I can

Pain has no significant effect on my social life apart from

manage if they are conveniently placed e.g. on a table

limiting my more energetic interests e.g. sport

Pain prevents me lifting heavy weights but I can manage light

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

to medium weights if they are conveniently positioned

Pain has restricted my social life to my home

I can only lift very light weights

I have no social life because of pain

I cannot lift or carry anything

Section 9: Travelling

Section 4: Walking

I can travel anywhere without pain

Pain does not prevent me walking any distance

I can travel anywhere but it gives me extra pain

Pain prevents me from walking more than 2 kilometers

Pain is bad but I manage journeys over 2 hours

Pain prevents me from walking more than 1 kilometer

Pain restricts me to journeys of less than 1 hour

Pain prevents me from walking more than 500 meters

Pain restricts me to short necessary journey under 30 minutes

I can only walk using a stick or crutches

Pain prevents me from travelling except to receive treatment

I am in bed most of the time

Section 10: Employment/Homemaking

Section 5: Sitting

My normal homemaking/job activities do not cause pain

I can sit in any chair as long as I like

My normal homemaking/job activities increase my pain, but I

can still perform all that is required of me.

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

I can perform most of my homemaking/job activities, but pain

Pain prevents me sitting more than one hour

prevents me from performing more physically stressful activities

Pain prevents me from sitting more than 30 minutes

(e.g. lifting, vacuuming.)

Pain prevents me from sitting more than 10 minutes

Pain prevents me from doing anything but light duties

Pain prevents me from sitting at all

Pain prevents me from doing even light duties

Paint prevents me from performing any job or homemaking

chores.

SCORE:

X 100 =

Anderson Chiropractic 7390 Business Center Dr. Avon, IN 46123 (317)272-7000

Oswestry Disability Index

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