Modified Oswestry Low Back Pain Disability Index Page 2
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1
2
3PHYSICAL THERAPY
WELLNESS SERVICES
PAIN MANAGEMENT
SPORTS ENHANCEMENT
MODIFIED OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE
Section 1: To be completed by patient
Name: ___________________________________
Age: _______
AD
Non-Active Duty
Occupation: ______________________________
Number of days of back pain: _______ (this episode)
Initial Date
Follow-up Date
Follow-up Date
Discharge/Follow-up Date
Section 2: To be completed by patient
Reset Column
Reset Column
Reset Column
Reset Column
Please only check boxes in the column for the evaluation date you are entering and only check one box per category.
Initial Evaluation
Follow-up
Follow-up
Discharge
Pain Intensity
The pain is mild and comes and goes. = 0
The pain is mild and does not vary much. = 1
The pain is moderate and comes and goes. = 2
The pain is moderate and does not vary much. = 3
The pain is severe and comes and goes. = 4
The pain is severe and does not vary much. = 5
Personal Care (Washing, Dressing, etc.)
I do not have to change the way I wash and dress myself to avoid pain. = 0
I do not normally change the way I wash or dress myself even though it
causes me some pain. = 1
Washing and dressing increases my pain, but I can do it without changing
my way of doing it. = 2
Washing and dressing increases my pain, and I find it necessary to change
the way I do it. = 3
Because of my pain I am partially unable to wash and dress without
help. = 4
Because of my pain I am completely unable to wash or dress without
help. = 5
Lifting
I can lift heavy weights without increased pain. = 0
I can lift heavy weights, but it causes increased pain. = 1
Pain prevents me from lifting heavy weights off of the floor, but I can
manage if they are conveniently positioned (ex. On a table, etc.) = 2
Pain prevents me from lifting heavy weights off of the floor, but I can
manage light to medium weights if they are conveniently positioned. = 3
I can lift only very light weights. = 4
I cannot lift or carry anything at all. = 5
Walking
I have no pain when walking. = 0
I have pain when walking, but I can still walk my required normal
distances. = 1
Pain prevents me from walking long distances. = 2
Pain prevents me from walking intermediate distances. = 3
Pain prevents me from walking even short distances. = 4
Pain prevents me from walking at all. = 5
Sitting
Sitting does not cause me any pain. = 0
I can only sit as long as I like providing that I have my choice of seating
surfaces. = 1
Pain prevents me from sitting for more than 1 hour. = 2
Pain prevents me from sitting for more than ½ hour. = 3
Pain prevents me from sitting for more than 10 minutes. = 4
Pain prevents me from sitting at all. = 5
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