Disability Index Questionnaire Form
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1REVISED OSWESTRY DISABILITY INDEX QUESTIONNAIRE
LAST NAME:
FIRST NAME:
MI:
Date:
Please select one answer for each question:
Section 6 – Standing (Remember, standing is NOT walking.):
Section 1 - Pain Intensity
0 The pain comes and goes and is very mild.
0 I can stand as long as I want without pain.
0 The pain is mild and does not very much.
0 I have some pain while standing, but it does not increase with
time.
0 The pain comes and goes and is moderate.
0 I cannot stand for longer than 1 hour without increasing pain.
0 The pain is moderate and does not very much.
0 I cannot stand for longer than ½ hour without increasing pain.
0 The pain comes and goes and is severe.
0 I cannot stand for longer than 10 minutes without increasing
pain.
0 The pain is severe and does not very much.
0 I avoid standing, because it increases the pain straight away.
Section 2 -- Personal Care (Washing, Dressing, etc.)
Section 7 -- Sleeping
0 I would not have to change my way of washing or dressing in
0 I get no pain in bed.
order to avoid pain.
0 I do not normally change my way of washing or dressing even
0 I get pain in bed, but it does not prevent me from sleeping
though it causes some pain.
well.
0 Washing and dressing increases the pain, but I manage not to
0 Because of pain, my normal night’s sleep is reduced by less
change my way of doing it.
than one quarter.
0 Washing and dressing increases the pain and I find it necessary
0 Because of pain, my normal night’s sleep is reduced by less
to change my way of doing it.
than one half.
0 Because of the pain, I am unable to do some washing and
0 Because of pain, my normal night’s sleep is reduced by less
dressing without help.
than one three-quarter.
0 Because of the pain, I am unable to do any washing or dressing
0 Pain prevents me from sleeping at all.
without help.
Section 3 – Lifting
Section 8 – Social Life
0 I can lift heavy weights without extra pain.
0 My social life is normal and gives me no pain.
0 I can lift heavy weights but it gives extra pain.
0 My social life is normal but increases the degree of pain.
0 Pain prevents me from lifting heavy weights off the floor.
0 Pain has no significant effect on my social life apart from
limiting my more energetic interests, e.g. dancing,etc.
0 Pain prevents me from lifting heavy weights off the floor, but I
0 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
table.
0 Pain prevents me from lifting heavy weights, but I can manage
0 Pain has restricted my social life to my home.
light to medium weights if they are conveniently positioned.
0 I can only lift very light weights, at the most.
0 I have hardly any social life because of pain.
Section 4 – Walking
Section 9– Traveling
0 Pain does not prevent me from walking any distance.
0 I get no pain while traveling.
0 Pain prevents me from walking more than one mile.
0 I get some pain while traveling, but none of my usual forms of
travel make it any worse.
0 Pain prevents me from walking more than ½ mile.
0 I get extra pain while traveling, but it does not compel me to
seek alternative forms of travel.
0 Pain prevents me from walking more than ¼ mile.
0 I get extra pain while traveling which compels me to seek
Alternative forms of travel.
0 I can only walk using a cane or crutches.
0 Pain restricts me for all forms of travel.
0 I am in bed most of the time and have to crawl to the toilet.
0 Pain prevents all forms of travel except if lying down.
Section 5 – Sitting (“Favorite chair” includes a recliner):
Section 10 – Changing Degree of Pain
0 I can sit in any chair as long as I like without pain.
0 My pain is rapidly getting better.
0 I can only sit in my favorite chair as long as I like.
0 My pain fluctuates but overall is definitely getting better.
0 Pain prevents me from sitting more than one hour.
0 My pain seems to be getting better but improvement is slow
at the present.
0 Pain prevents me from sitting more than ½ hour.
0 My pain is neither getting better nor worse.
0 Pain prevents me from sitting more than 10 minutes.
0 My pain is gradually worsening.
0 Pain prevents me from sitting.
0 My pain is rapidly worsening.
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Parent category: Life