Modified Oswestry Low Back Pain Disability Index Page 3
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1
2
3PHYSICAL THERAPY
WELLNESS SERVICES
PAIN MANAGEMENT
SPORTS ENHANCEMENT
OSWESTRY QUESTIONNAIRE, p.2
Section 2 (Con’t): To be completed by patient
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
Standing
I can stand as long as I want without increased pain. = 0
I can stand as long as I want, but my pain increases with time. = 1
Pain prevents me from standing for more than 1 hour. = 2
Pain prevents me from standing more than ½ hour. = 3
Pain prevents me from standing more than 10 minutes. = 4
I avoid standing because it increases my pain right away. = 5
Sleeping
I get no pain when I am in bed. = 0
I get pain in bed, but it does not prevent me from sleeping well. = 1
Because of my pain, my sleep is ¾ of my normal amount. = 2
Because of my pain, my sleep is ½ of my normal amount. = 3
Because of my pain, my sleep is ¼ of my normal amount. = 4
Pain prevents me from sleeping at all. = 5
Social Life
My social life is normal and does not increase my pain. = 0
My social life is normal, but it increases my level of pain. = 1
Pain prevents me from participating in more energetic activities (ex.
sports, dancing, etc.) = 2
Pain prevents me from going out very often. = 3
Pain has restricted my social life to my home. = 4
I have hardly any social life because of my pain. = 5
Traveling
I get no increased pain when traveling. = 0
I get some pain while traveling, but none of my usual forms of travel
make it any worse. = 1
I get increased pain while traveling, but it does not cause me to seek
alternative forms of travel. = 2
I get increased pain while traveling which causes me to seek alternatives
forms of travel. = 3
My pain restricts all forms of travel except that which is done while I am
lying down. = 4
My pain restricts all forms of travel. = 5
Employment/Homemaking
My normal job/homemaking activities do not cause pain. = 0
My normal job/homemaking activities increase pain, but I can still
perform all that is required of me. = 1
I can perform most of my job/homemaking duties, but pain prevents me
from performing more physically stressful activities (ex. lifting,
vacuuming) = 2
Pain prevents me from doing anything but light duties. = 3
Pain prevents me from doing even light duties. = 4
Pain prevents me from performing any job or homemaking chores. = 5
Section 3: To be completed by physical therapist/provider
SCORE: Initial _____ out of 50
Subsequent _____/50
Subsequent _____/50
Discharge _____/50
0
0
0
0
(SEM 5, MDC 7)
Number of Treatment Sessions: _____________________
Diagnosis/ICD-9 Code: _____________________________
Adapted from Hudson-Cook N, Tomes-Nicholson K, Breen A. A revised oswestry disability questionnaire. In: Roland M, Jenner J,
eds. Back Pain: New Approaches to Rehabilitation and Education. New York: Manchester University Press; 1989. p. 187-204
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