Back Odi Questionnaire Template - Coa printable pdf download

Date: _______________________

□ Male

□ Female

Date of Birth: _____________________

(month/day/year)

Raphael R. Roybal, MD

Age: ______________

Patient Name: _________________________________________________________________________________________________________

Back ODI Questionnaire

This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by

marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely

describes your problem.

Pain Intensity

Personal Care

① The pain comes and goes and is very mild.

① I do not have to change my way of washing or dressing in order to avoid pain.

② The pain is mild and does not vary much.

② I do not normally change my way of washing or dressing even though it

③ The pain comes and goes and is moderate.

causes some pain.

④ The pain is moderate and does not vary much.

③ Washing and dressing increases the pain but I manage not to change

⑤ The pain comes and goes and is very severe.

my way of doing it.

⑥ The pain is very severe and does not vary much.

④ Washing and dressing increases the pain and I find it necessary to change

my way of doing it.

⑤ Because of the pain I am unable to do some washing and dressing without help.

⑥ Because of the pain I am unable to do any washing and dressing without help.

Sleeping

Lifting

① I get no pain in bed.

① I can lift heavy weights without extra pain.

② I get pain in bed but it does not prevent me from sleeping well.

② I can lift heavy weights but it causes extra pain.

③ Because of pain my normal sleep is reduced by less than 25%.

③ Pain prevents me from lifting heavy weights off the floor.

④ Because of pain my normal sleep is reduced by less than 50%.

④ Pain prevents me from lifting heavy weights off the floor, but I can manage

⑤ Because of pain my normal sleep is reduced by less than 75%.

if they are conveniently positioned (e.g. , on a table).

⑥ Pain prevents me from sleeping at all.

⑤ Pain prevents me from lifting heavy weights off the floor, but I can manage

light to medium weights if they are conveniently positioned.

⑥ I can only lift very light weights.

Sitting

Traveling

① I can sit in any chair as long as I like.

① I get no pain while traveling.

② I can only sit in my favorite chair as long as I like.

② I get some pain while traveling but none of my usual forms of travel

③ Pain prevents me from sitting more than 1 hour.

make it worse.

④ Pain prevents me from sitting more than 112 hour.

③ I get extra pain while traveling but it does not cause me to seek alternate

⑤ Pain prevents me from sitting more than 10 minutes.

forms of travel.

⑥ I avoid sitting because it increases pain immediately.

④ I get extra pain while traveling which causes me to seek alternate forms of travel.

⑤ Pain restricts all forms of travel except that done while lying down.

⑥ Pain restricts all forms of travel.

Standing

Social Life

① I can stand as long as I want without pain.

① My social life is normal and gives me no extra pain.

② I have some pain while standing but it does not increase with time. ② My social life is normal but increases the degree of pain.

③ I cannot stand for longer than 1 hour without increasing pain.

③ Pain has no significant affect on my social life apart from limiting my more

④ I cannot stand for longer than 112 hour without increasing pain.

energetic interests (e.g., dancing, etc.).

⑤ I cannot stand for longer than 10 minutes without increasing pain.

④ Pain has restricted my social life and I do not go out very often.

⑥ I avoid standing because it increases pain immediately.

⑤ Pain has restricted my social life to my home.

⑥ I have hardly any social life because of the pain.

Walking

Changing degree of pain

① I have no pain while walking.

① My pain is rapidly getting better.

② I have some pain while walking but it doesn't increase with distance. ② My pain fluctuates but overall is definitely getting better.

③ I cannot walk more than 1 mile without increasing pain.

③ My pain seems to be getting better but improvement is slow.

④ I cannot walk more than 112 mile without increasing pain.

④ My pain is neither getting better or worse.

⑤ I cannot walk more than 114 mile without increasing pain.

⑤ My pain is gradually worsening.

⑥ I cannot walk at all without increasing pain.

⑥ My pain is rapidly worsening.

Back Odi Questionnaire Template - Coa

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