"Pdr Oswestry Neck Pain Questionnaire Template"

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NAME:____________________________________
DATE
: _________________________________________
PDR Oswestry Neck Pain Questionnaire
This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage everyday activities. Please
answer each Section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate
to you, but Please circle the one choice which closely describes your problem right now.
Section 6 – Concentration
Section 1 – Pain Intensity
A.
I can concentrate fully when I want to with no difficulty.
A.
I have no pain at the moment.
B.
I can concentrate fully when I want to with slight difficulty.
B.
The pain is mild at the moment.
C. I have a fair degree of difficulty in concentrating when I
C. The pain comes and goes and is moderate
want to.
D. The pain moderate and does not vary much.
D. I have a lot of difficulty in concentrating when I want to.
E.
The pain is severe, but comes and goes.
E.
I have a great deal of difficulty in concentrating when I
F.
The pain is severe and does not vary much.
want to.
F.
I cannot concentrate at all.
Section 2 – Personal Care
A.
I can look after myself without causing extra pain.
Section 7 – Work
B.
I can look after myself normally, but it causes extra pain.
A.
I can do as much work as I want to.
C. It is painful to look after myself and I am slow and
B.
I can do my usual work but no more.
careful.
C. I can do most of my usual work, but no more.
D. I need some help, but manage most of my personal
D. I cannot do my usual work.
care.
E.
I can hardly do any work at all.
E.
I need help every day in most aspects of self-care.
F.
I cannot do any work at all.
F.
I do not get undressed, I wash with difficulty and stay in
bed.
Section 8 -- Driving
A.
I can drive my car without any neck pain.
Section 3 – Lifting
B.
I can drive my car as long as I want with slight pain in my
A.
I can lift heavy weights without extra pain.
neck.
B.
I can lift heavy weights but it causes extra pain.
C. I can drive my car as long as I want with moderate pain
C. Pain prevents me from lifting heavy weights off the floor,
in my neck.
But I can manage if they are conveniently positioned
D. I cannot drive my car as long as I want because of
(e.g on a table)
moderate pain in my neck.
D. Pain prevents me from lifting heavy weights, but I can
E.
I can hardly drive at all because of severe pain in my
manage light to medium weights if they are conveniently
neck.
positioned.
F.
I cannot drive my car at all.
E.
I can lift only very light weights.
I cannot lift or carry anything at all.
F.
Section 9 – Sleeping
Section 4 – Reading
A.
I have no trouble sleeping.
B.
My sleep is slightly disturbed (less than 1 hour
A.
I can read as much as I want to with no pain in my neck.
sleepless).
B.
I can read as much as I want to with slight pain in my
C. My sleep is mildly disturbed (1-2 hours sleepless).
neck.
D. My sleep is moderately disturbed (2-3 hours sleepless).
C. I can read as much as I want to with moderate pain in my
E.
My sleep is greatly disturbed (3-5 hours sleepless).
neck.
F.
My sleep is completely disturbed (5-7 hours sleepless).
D. I cannot read as much as I want to because of moderate
pain in my neck.
Section 10 – Recreation
E.
I cannot read as much as I want to because of severe
pain in my neck
A.
I am able to engage in all my recreational activities, with
F.
I cannot read at all.
no neck pain at all.
B.
I am able to engage in all of my recreational activities,
Section 5 – Headache
with some pain in my neck.
A.
I have no headaches at all.
C. I am able to engage in most, but not all of my usual
B.
I have slight headaches that come infrequently.
recreational activities because of pain in my neck.
C. I have moderate headaches that come infrequently.
D. I am able to engage in only a few of my usual
D. I have moderate headaches that come frequently.
recreational activities because of pain in my neck.
E.
I have severe headaches that come frequently.
E.
I can hardly do any recreational activities because of
F.
I have headaches almost all the time.
pain in my neck.
F.
I cannot do any recreational activities at all.
Section 11 – Numeric Rating Scale (NRS)
Try and assign a number from 0 to 10 to your current pain level. If you have no
OSW-SCORE:_____%
pain, use a 0. As the numbers get higher, they stand for pain that is getting
worse. A 10 means the pain is as bad as it can be.
0
1
2
3
4
5
6
7
8
9
10
P-SCORE:________
No pain
Mild
Moderate
Severe
Worst Possible
Pain
NAME:____________________________________
DATE
: _________________________________________
PDR Oswestry Neck Pain Questionnaire
This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage everyday activities. Please
answer each Section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate
to you, but Please circle the one choice which closely describes your problem right now.
Section 6 – Concentration
Section 1 – Pain Intensity
A.
I can concentrate fully when I want to with no difficulty.
A.
I have no pain at the moment.
B.
I can concentrate fully when I want to with slight difficulty.
B.
The pain is mild at the moment.
C. I have a fair degree of difficulty in concentrating when I
C. The pain comes and goes and is moderate
want to.
D. The pain moderate and does not vary much.
D. I have a lot of difficulty in concentrating when I want to.
E.
The pain is severe, but comes and goes.
E.
I have a great deal of difficulty in concentrating when I
F.
The pain is severe and does not vary much.
want to.
F.
I cannot concentrate at all.
Section 2 – Personal Care
A.
I can look after myself without causing extra pain.
Section 7 – Work
B.
I can look after myself normally, but it causes extra pain.
A.
I can do as much work as I want to.
C. It is painful to look after myself and I am slow and
B.
I can do my usual work but no more.
careful.
C. I can do most of my usual work, but no more.
D. I need some help, but manage most of my personal
D. I cannot do my usual work.
care.
E.
I can hardly do any work at all.
E.
I need help every day in most aspects of self-care.
F.
I cannot do any work at all.
F.
I do not get undressed, I wash with difficulty and stay in
bed.
Section 8 -- Driving
A.
I can drive my car without any neck pain.
Section 3 – Lifting
B.
I can drive my car as long as I want with slight pain in my
A.
I can lift heavy weights without extra pain.
neck.
B.
I can lift heavy weights but it causes extra pain.
C. I can drive my car as long as I want with moderate pain
C. Pain prevents me from lifting heavy weights off the floor,
in my neck.
But I can manage if they are conveniently positioned
D. I cannot drive my car as long as I want because of
(e.g on a table)
moderate pain in my neck.
D. Pain prevents me from lifting heavy weights, but I can
E.
I can hardly drive at all because of severe pain in my
manage light to medium weights if they are conveniently
neck.
positioned.
F.
I cannot drive my car at all.
E.
I can lift only very light weights.
I cannot lift or carry anything at all.
F.
Section 9 – Sleeping
Section 4 – Reading
A.
I have no trouble sleeping.
B.
My sleep is slightly disturbed (less than 1 hour
A.
I can read as much as I want to with no pain in my neck.
sleepless).
B.
I can read as much as I want to with slight pain in my
C. My sleep is mildly disturbed (1-2 hours sleepless).
neck.
D. My sleep is moderately disturbed (2-3 hours sleepless).
C. I can read as much as I want to with moderate pain in my
E.
My sleep is greatly disturbed (3-5 hours sleepless).
neck.
F.
My sleep is completely disturbed (5-7 hours sleepless).
D. I cannot read as much as I want to because of moderate
pain in my neck.
Section 10 – Recreation
E.
I cannot read as much as I want to because of severe
pain in my neck
A.
I am able to engage in all my recreational activities, with
F.
I cannot read at all.
no neck pain at all.
B.
I am able to engage in all of my recreational activities,
Section 5 – Headache
with some pain in my neck.
A.
I have no headaches at all.
C. I am able to engage in most, but not all of my usual
B.
I have slight headaches that come infrequently.
recreational activities because of pain in my neck.
C. I have moderate headaches that come infrequently.
D. I am able to engage in only a few of my usual
D. I have moderate headaches that come frequently.
recreational activities because of pain in my neck.
E.
I have severe headaches that come frequently.
E.
I can hardly do any recreational activities because of
F.
I have headaches almost all the time.
pain in my neck.
F.
I cannot do any recreational activities at all.
Section 11 – Numeric Rating Scale (NRS)
Try and assign a number from 0 to 10 to your current pain level. If you have no
OSW-SCORE:_____%
pain, use a 0. As the numbers get higher, they stand for pain that is getting
worse. A 10 means the pain is as bad as it can be.
0
1
2
3
4
5
6
7
8
9
10
P-SCORE:________
No pain
Mild
Moderate
Severe
Worst Possible
Pain