Low Back Pain printable pdf download

Ref. No. (CRN): _______________

The Oswestry Disability Index for

Ref. No. (NHS): _______________

Low Back Pain

____________________

Surname:

Oswestry Outcome

Centre

Questionnaire

First Name(s): ________________

Date of Birth: ___/___/___

Occupation___________________

How long have you had back pain Years____ Months _____ Weeks_____

How long have you had leg pain

Years____ Months _____ Weeks_____

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY:

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 realise 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 2 - PERSONAL CARE (Washing, Dressing, etc.)

SECTION 1 - PAIN INTENSITY

My pain is mild to moderate: I do not need pain killers.

I can look after myself normally without causing extra pain.

The pain is bad, but I manage without taking pain killers.

I can look after myself normally but it causes extra pain.

Pain killers give complete relief from pain.

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

Pain killers give moderate relief from pain.

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

Pain killers give very little relief from pain.

I need help everyday in most aspects of self care.

Pain killers have no effect on the pain.

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

SECTION 3 - LIFTING

SECTION 4 - WALKING

I can lift heavy weights without extra pain.

I can walk as far as I wish.

I can lift heavy weights but it gives extra pain.

Pain prevents me walking more than 1 mile.

Pain prevents me walking more than 0.5 mile.

Pain prevents me from lifting heavy weights off the floor,

but I can manage if they are conveniently positioned,

Pain prevents me walking more than 0.25 mile.

e.g., on a table.

I can walk only if I use a stick or crutches.

Pain prevents me from lifting heavy weights but I can

I am in bed or in a chair for most of everyday.

manage light weights if they are conveniently positioned.

I can lift only very light weights.

I cannot lift or carry anything at all.

SECTION 6 - STANDING

SECTION 5 - SITTING

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

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

I can sit in my favorite chair as long as

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

I like.

Pain prevents me from standing for more than 1 hour.

Pain prevents me from sitting more than 1 hour.

Pain prevents me from standing for more than 30 minutes.

Pain prevents me from sitting more than 1/2 hour.

Pain prevents me from standing for more than 10 minutes.

Pain prevents me from sitting more than 10 minutes.

Pain prevents me from standing at all.

Pain prevents me from sitting at all.

Please turn over

and complete page 2

Low Back Pain

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