Revised Oswestry Disability Index Questionnaire Template
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1REVISED OSWESTRY
OSWESTRY DISABILITY INDEX QUESTIONNAIRE
LAST NAME: _____________________ FIRST NAME: ___________________ MI: ____ Date: ____________________
LAST NAME: _____________________ FIRST NAME: ___________________ MI: ____ Date: ____________________
LAST NAME: _____________________ FIRST NAME: ___________________ MI: ____ Date: ____________________
Please select one answer for each question:
Section 1 - Pain Intensity
Section 6 – Standing (Remember, standing is NOT walking.):
(Remember, standing is NOT walking.):
The pain comes and goes and is very mild.
I can stand as long as I want without pain.
I can stand as long as I want without pain.
The pain is mild and does not vary much.
I have some pain while standing, but it does not increase with
I have some pain while standing, but it does not increase with
time.
The pain comes and goes and is moderate.
I cannot stand for longer than 1 hour without increasing pain.
I cannot stand for longer than 1 hour without increasing pain.
The pain is moderate and does not vary much.
I cannot stand for longer than ½ hour without increasing pain.
½ hour without increasing pain.
The pain comes and goes and is severe.
I cannot stand for longer than 10 minutes without increasing
10 minutes without increasing
pain.
The pain is severe ad does not vary much.
I avoid standing, because it increases the pain straight away.
I avoid standing, because it increases the pain straight away.
Section 2 -- Personal Care (Washing, Dressing, etc.)
(Washing, Dressing, etc.)
Section 7 -- Sleeping
I would not have to change my way of washing or dressing in
I would not have to change my way of washing or dressing in
I get no pain in bed.
order to avoid pain
I do not normally change my way of washing or dressing even
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
pain in bed, but it does not prevent me from sleeping
though it causes some pain.
well.
Washing and dressing increases the pain, but I manage not to
Washing and dressing increases the pain, but I manage not to
Because of pain, my normal night’s sleep is reduced by less
Because of pain, my normal night’s sleep is reduced by less
change my way of doing it.
than one than one quarter.
Washing and dressing increases the pain and I find it necessary
Washing and dressing increases the pain and I find it necessary
Because of pain, my normal night’s sleep is reduced by less
Because of pain, my normal night’s sleep is reduced by less
to change my way of doing it.
than one half.
Because of the pain, I am unable to do some washing and
Because of the pain, I am unable to do some washing and
Because of pain, my normal night’s sleep is reduced by less
Because of pain, my normal night’s sleep is reduced by less
dressing without help.
than one than three-quarter.
Because of the pain, I am unable to do any washing or dressing
Because of the pain, I am unable to do any washing or dressing
Pain prevents me from sleeping at all.
Pain prevents me from sleeping at all.
without help.
Section 3 – Lifting
Section 8 – Social Life
I can lift heavy weights without extra pain.
My social life is normal and gives me no pain.
My social life is normal and gives me no pain.
I can lift heavy weights but it gives extra pain.
My social life is normal but increases the degree of pain.
My social life is normal but increases the degree of pain.
Pain prevents me from lifting heavy weights off the floor
weights off the floor
Pain has no significant effect on my social life apart from
Pain has no significant effect on my social life apart from
limiting my more energetic interests, e.g. dancing,etc.
limiting my more energetic interests, e.g. dancing,etc.
Pain prevents me from lifting heavy weights off the floor, but I
Pain prevents me from lifting heavy weights off the floor, but I
Pain has restricted my social life and I do not go out as often.
Pain has restricted my social life and I do not go out as often.
can manage if they are conveniently positioned, for example on a
, for example on a
table.
Pain prevents me from lifting heavy weights, but I can manage
Pain prevents me from lifting heavy weights, but I can manage
Pain has restricted my social life to my home.
e to my home.
light to medium weights if they are conveniently positioned.
light to medium weights if they are conveniently positioned.
I can only lift very light weights, at the most
I have hardly any social life because of pain.
I have hardly any social life because of pain.
Section 4 – Walking
Section 9– Traveling
Pain does not prevent me from walking any distance.
Pain does not prevent me from walking any distance.
I get no pain while traveling.
Pain prevents me from walking more than one mile.
prevents me from walking more than one mile.
I get some pain while traveling, but none of my usual forms of
I get some pain while traveling, but none of my usual forms of
travel make it any worse.
Pain prevents me from walking more than ½ mile.
Pain prevents me from walking more than ½ mile.
I get extra pain while traveling, but it does not compel me to
I get extra pain while traveling, but it does not compel me to
seek alternative forms of travel.
Pain prevents me from walking more than ¼ mile
Pain prevents me from walking more than ¼ mile
I get extra pain while traveling which compels me to seek
I get extra pain while traveling which compels me to seek
alternative forms of travel.
I can only walk using a cane or crutches
Pain restricts me for all forms of travel.
Pain restricts me for all forms of travel.
I am in bed most of the time and have to crawl to the toilet.
I am in bed most of the time and have to crawl to the toilet.
Pain prevents all forms of travel except that down lying down.
Pain prevents all forms of travel except that down lying down.
Section 5 – Sitting (“Favorite chair” includes a recliner.):
recliner.):
Section 10 – Changing Degree of Pain
Changing Degree of Pain
I can sit in any chair as long as I like without pain.
I can sit in any chair as long as I like without pain.
My pain is rapidly getting better.
My pain is rapidly getting better.
I can only sit in my favorite chair as long as I like
I can only sit in my favorite chair as long as I like
My pain fluctuates but overall is definitely
My pain fluctuates but overall is definitely getting better.
Pain prevents me from sitting more than one hour.
Pain prevents me from sitting more than one hour.
My pain seems to be getting better but improvement is slow
My pain seems to be getting better but improvement is slow
at the present.
Pain prevents me from sitting more than ½ hour.
Pain prevents me from sitting more than ½ hour.
My pain is neither getting better nor worse.
My pain is neither getting better nor worse.
Pain prevents me from sitting more than 10 minutes.
prevents me from sitting more than 10 minutes.
My pain is gradually worsening.
Pain prevents me from sitting
My pain is rapidly worsening.
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