Oswestry Low Back Disability Questionnaire Template
Download a blank fillable Oswestry Low Back Disability Questionnaire Template in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Oswestry Low Back Disability Questionnaire Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Oswestry Low Back Disability Questionnaire
Please select the appropriate answer in each section,
with respect to your low back.
Oswestry Disability Index
Section 7 – Sleeping
Section 1 – Pain Intensity
My sleep is never disturbed by pain.
My sleep is occasionally disturbed by pain.
I have no pain at the moment.
Because of pain, I have less than 6 hours sleep.
The pain is very mild at the moment.
Because of pain, I have less than 4 hours sleep.
The pain is moderate at the moment.
Because of pain, I have less than 2 hours sleep.
Pain prevents me from sleeping at all.
The pain is fairly severe at the moment.
The pain is very severe at the moment.
Section 8 – Sex life (if applicable)
The pain is the worst imaginable at the moment.
Section 2 – Personal Care (washing, dressing, etc.)
My sex life is normal and causes no extra pain.
My sex life is normal but causes some extra pain.
I can look after myself normally but it is very painful.
My sex life is nearly normal but is very painful.
My sex life is severely restricted by pain.
I can look after myself normally but it is very painful.
It is painful to look after myself and I am slow and careful.
My sex life is nearly absent because of pain.
Pain prevents any sex life at all.
I need some help but manage most of my personal care.
I need help every day in most aspects of my personal care.
Section 9 – Social Life
I need help every day in most aspects of self-care.
I do not get dressed, wash with difficulty, and stay in bed.
My social life is normal and cause me no extra pain.
Section 3 - Lifting
My social life is normal but increases the degree of pain.
Pain has no significant effect on my social life apart from limitingmy
I can lift heavy weights without extra pain.
more energetic interests, i.e. sports.
I can lift heavy weights but it gives extra pain.
Pain has restricted my social life and I do not go out as often.
Pain prevents me from lifting heavy weights off the floor, but I can
Pain has restricted social life to my home.
manage if they are conveniently positioned (i.e. on a table).
I have no social life because of pain.
Pain prevents me from lifting heavy weights, but I can manage light to
Section 10 – Traveling
medium weights if they are conveniently positioned.
I can lift only very light weights.
I can travel anywhere without pain.
I cannot lift or carry anything at all.
I can travel anywhere but it gives extra pain.
Section 4 – Walking
Pain is bad but I manage journeys of over two hours.
Pain restricts me to short necessary journeys under 30 minutes.
Pain does not prevent me walking any distance.
Pain prevents me from traveling except to receive treatment.
Pain prevents me walking more than 1mile.
Pain prevents me walking more than ¼ of a mile.
Section 11 - Previous Treatment
Pain prevents me walking more than 100 yards.
I can only walk using a stick or crutches.
Over the past three months have you received treatment, tablets or
I am in bed most of the time and have to crawl to the toilet.
medicines of any kind for your back or leg pain? Please check the
appropriate box.
Section 5 – Sitting
No
Yes (if yes, please state the type of treatment you have received)
I can sit in any chair as long as I like.
Treatment _______________________________________
I can sit in my favorite chair as long as I like.
________________________________________________
Pain prevents me from sitting for more than 1 hour.
Pain prevents me from sitting for more than ½ hour.
Pain prevents me from sitting for more than 10
minutes.
Pain prevents me from sitting at all.
Section 6 – Standing
I can stand as long as I want without extra pain.
I can stand as long as I want but it gives me extra pain.
Pain prevents me from standing more than 1 hour.
Pain prevents me from standing for more than ½ an hour.
Pain prevents me from standing for more than 10 minutes.
Pain prevents me from standing at all.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life