Oswestry Disability Index Questionnaire Template printable pdf download

swestry

isability

nDex

Patient Name:___________________________________________________

Date:_______/_______/_______

Please read instructions carefully.

This questionnaire has been designed to give the doctor information as to how your low back pain has affected your ability to man-

age everyday life. Please read all statements in each section and mark one box which most closely describes your problem overall.

SECTION 1 - PAIN INTENSITY

SECTION 6 - STANDING

The pain comes and goes and is very mild.

I can stand as long as I want without pain.

❏

The pain is mild and does not vary much.

I have some pain on standing but it does not increase with time.

❏

The pain comes and goes and 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 longer than 10 minutes without increasing pain.

❏

The pain is severe and does not vary much.

I avoid standing because it increases the pain.

❏

SECTION 2 - PERSONAL CARE (washing, dressing, etc.)

SECTION 7 - SLEEPING

I do not have to change my way of washing or dressing to avoid pain.

I get no pain in bed.

❏

I do not normally change my way of washing or dressing even

I get pain in bed but it does not prevent me from sleeping well.

❏

though it causes some pain.

Pain reduces my normal sleep by 1/4 each night.

❏

Washing and dressing increases the pain but I manage not to

Pain reduces my normal sleep by ½ each night.

❏

change my way of doing it.

Pain reduces my normal sleep by 3/4 each night.

❏

Washing and dressing increases the pain and I find it necessary

Pain prevents me from sleeping at all.

❏

to change my way of doing it.

Because of the pain, I am unable to do some washing and

SECTION 8 - SOCIAL LIFE

❏

dressing without help.

My social life is normal and gives me no pain.

❏

Because of the pain, I am unable to do any washing and

My social life is normal but increases the degree of pain.

❏

dressing without help.

My social life is unaffected by pain apart from limiting more

❏

energetic interests.

SECTION 3 - LIFTING

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

❏

I can lift heavy objects without any extra pain.

Pain has restricted my social life to my home.

❏

I can lift heavy objects, but it gives extra pain.

I have hardly any social life because of the pain.

❏

Pain prevents me from lifting heavy objects off the floor.

❏

Pain prevents me from lifting heavy objects off the floor but I

SECTION 9 - DRIVING / RIDING IN CAR, ETC.

❏

can manage if they are conveniently positioned on the floor.

I get no pain while traveling.

❏

Pain prevents me from lifting heavy objects but I can manage

I get some pain while traveling but none of my usual forms of

❏

light to medium objects.

travel make it worse.

I can only lift very light objects at the most.

I get extra pain while traveling but it does not compel me to

❏

seek alternate forms of travel.

SECTION 4 - WALKING

I get extra pain while traveling which compels me to seek

❏

I have no pain on walking.

alternate forms of travel.

❏

I have some pain but it does not increase with distance.

Pain restricts all forms of travel.

❏

I cannot walk more than one mile without increasing pain.

Pain prevents all forms of travel except that done lying down.

❏

I cannot walk more than ½ mile without increasing pain.

❏

I can only walk while using a cane or on crutches.

SECTION 10 - CHANGING DEGREE OF PAIN

❏

I cannot walk at all without increasing pain and have

My pain is rapidly getting better.

❏

to crawl to the toilet.

My pain fluctuates but overall is definitely getting better.

❏

My pain seems to be getting better but improvement is slow at

❏

SECTION 5 - SITTING

present.

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

My pain is neither getting better or worse.

❏

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

My pain is gradually worsening.

❏

Pain prevents me from sitting more than one hour.

My pain is rapidly worsening.

❏

Pain prevents me from sitting more than half an hour.

❏

Pain prevents me from sitting more than 10 minutes.

❏

I avoid sitting because it increases pain.

❏

Revised Oswestry Low Back Pain Questionnaire

Fairbank J, Davies J, et al. The Oswestry Back Pain Disability

Questionnaire. Physiotherapy 1980;66(18):271-273.

Updated 02/09

Oswestry Disability Index Questionnaire Template

Related Articles

Related forms

Related Categories