"Oswestry Disability Index Questionnaire Template - Mayfield Clinic"

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O
swestry
D
i
isability
nDex
Patient Name:___________________________________________________
Date:_______/_______/_______
Please read instructions carefully.
This questionnaire has been designed to give the doctor information as to how your low back pain has affected your ability to man-
age everyday life. Please read all statements in each section and mark one box which most closely describes your problem overall.
SECTION 1 - PAIN INTENSITY
SECTION 6 - STANDING
The pain comes and goes and is very mild.
I can stand as long as I want without pain.
The pain is mild and does not vary much.
I have some pain on standing but it does not increase with time.
The pain comes and goes and is moderate.
I cannot stand for longer than one hour without increasing pain.
The pain is moderate and does not vary much.
I cannot stand for longer than ½ hour without increasing pain.
The pain comes and goes and is very severe.
I cannot stand longer than 10 minutes without increasing pain.
The pain is severe and does not vary much.
I avoid standing because it increases the pain.
SECTION 2 - PERSONAL CARE (washing, dressing, etc.)
SECTION 7 - SLEEPING
I do not have to change my way of washing or dressing to avoid pain.
I get no pain in bed.
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 well.
though it causes some pain.
Pain reduces my normal sleep by 1/4 each night.
Washing and dressing increases the pain but I manage not to
Pain reduces my normal sleep by ½ each night.
change my way of doing it.
Pain reduces my normal sleep by 3/4 each night.
Washing and dressing increases the pain and I find it necessary
Pain prevents me from sleeping at all.
to change my way of doing it.
Because of the pain, I am unable to do some washing and
SECTION 8 - SOCIAL LIFE
dressing without help.
My social life is normal and gives me no pain.
Because of the pain, I am unable to do any washing and
My social life is normal but increases the degree of pain.
dressing without help.
My social life is unaffected by pain apart from limiting more
energetic interests.
SECTION 3 - LIFTING
Pain has restricted my social life and I do not go out very often.
I can lift heavy objects without any extra pain.
Pain has restricted my social life to my home.
I can lift heavy objects, but it gives extra pain.
I have hardly any social life because of the pain.
Pain prevents me from lifting heavy objects off the floor.
Pain prevents me from lifting heavy objects off the floor but I
SECTION 9 - DRIVING / RIDING IN CAR, ETC.
can manage if they are conveniently positioned on the floor.
I get no pain while traveling.
Pain prevents me from lifting heavy objects but I can manage
I get some pain while traveling but none of my usual forms of
light to medium objects.
travel make it worse.
I can only lift very light objects at the most.
I get extra pain while traveling but it does not compel me to
seek alternate forms of travel.
SECTION 4 - WALKING
I get extra pain while traveling which compels me to seek
I have no pain on walking.
alternate forms of travel.
I have some pain but it does not increase with distance.
Pain restricts all forms of travel.
I cannot walk more than one mile without increasing pain.
Pain prevents all forms of travel except that done lying down.
I cannot walk more than ½ mile without increasing pain.
I can only walk while using a cane or on crutches.
SECTION 10 - CHANGING DEGREE OF PAIN
I cannot walk at all without increasing pain and have
My pain is rapidly getting better.
to crawl to the toilet.
My pain fluctuates but overall is definitely getting better.
My pain seems to be getting better but improvement is slow at
SECTION 5 - SITTING
present.
I can sit in any chair as long as I like.
My pain is neither getting better or worse.
I can only sit in my favorite chair as long as I like.
My pain is gradually worsening.
Pain prevents me from sitting more than one hour.
My pain is rapidly worsening.
Pain prevents me from sitting more than half an hour.
Pain prevents me from sitting more than 10 minutes.
I avoid sitting because it increases pain.
Revised Oswestry Low Back Pain Questionnaire
Fairbank J, Davies J, et al. The Oswestry Back Pain Disability
Questionnaire. Physiotherapy 1980;66(18):271-273.
Updated 02/09
O
swestry
D
i
isability
nDex
Patient Name:___________________________________________________
Date:_______/_______/_______
Please read instructions carefully.
This questionnaire has been designed to give the doctor information as to how your low back pain has affected your ability to man-
age everyday life. Please read all statements in each section and mark one box which most closely describes your problem overall.
SECTION 1 - PAIN INTENSITY
SECTION 6 - STANDING
The pain comes and goes and is very mild.
I can stand as long as I want without pain.
The pain is mild and does not vary much.
I have some pain on standing but it does not increase with time.
The pain comes and goes and is moderate.
I cannot stand for longer than one hour without increasing pain.
The pain is moderate and does not vary much.
I cannot stand for longer than ½ hour without increasing pain.
The pain comes and goes and is very severe.
I cannot stand longer than 10 minutes without increasing pain.
The pain is severe and does not vary much.
I avoid standing because it increases the pain.
SECTION 2 - PERSONAL CARE (washing, dressing, etc.)
SECTION 7 - SLEEPING
I do not have to change my way of washing or dressing to avoid pain.
I get no pain in bed.
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 well.
though it causes some pain.
Pain reduces my normal sleep by 1/4 each night.
Washing and dressing increases the pain but I manage not to
Pain reduces my normal sleep by ½ each night.
change my way of doing it.
Pain reduces my normal sleep by 3/4 each night.
Washing and dressing increases the pain and I find it necessary
Pain prevents me from sleeping at all.
to change my way of doing it.
Because of the pain, I am unable to do some washing and
SECTION 8 - SOCIAL LIFE
dressing without help.
My social life is normal and gives me no pain.
Because of the pain, I am unable to do any washing and
My social life is normal but increases the degree of pain.
dressing without help.
My social life is unaffected by pain apart from limiting more
energetic interests.
SECTION 3 - LIFTING
Pain has restricted my social life and I do not go out very often.
I can lift heavy objects without any extra pain.
Pain has restricted my social life to my home.
I can lift heavy objects, but it gives extra pain.
I have hardly any social life because of the pain.
Pain prevents me from lifting heavy objects off the floor.
Pain prevents me from lifting heavy objects off the floor but I
SECTION 9 - DRIVING / RIDING IN CAR, ETC.
can manage if they are conveniently positioned on the floor.
I get no pain while traveling.
Pain prevents me from lifting heavy objects but I can manage
I get some pain while traveling but none of my usual forms of
light to medium objects.
travel make it worse.
I can only lift very light objects at the most.
I get extra pain while traveling but it does not compel me to
seek alternate forms of travel.
SECTION 4 - WALKING
I get extra pain while traveling which compels me to seek
I have no pain on walking.
alternate forms of travel.
I have some pain but it does not increase with distance.
Pain restricts all forms of travel.
I cannot walk more than one mile without increasing pain.
Pain prevents all forms of travel except that done lying down.
I cannot walk more than ½ mile without increasing pain.
I can only walk while using a cane or on crutches.
SECTION 10 - CHANGING DEGREE OF PAIN
I cannot walk at all without increasing pain and have
My pain is rapidly getting better.
to crawl to the toilet.
My pain fluctuates but overall is definitely getting better.
My pain seems to be getting better but improvement is slow at
SECTION 5 - SITTING
present.
I can sit in any chair as long as I like.
My pain is neither getting better or worse.
I can only sit in my favorite chair as long as I like.
My pain is gradually worsening.
Pain prevents me from sitting more than one hour.
My pain is rapidly worsening.
Pain prevents me from sitting more than half an hour.
Pain prevents me from sitting more than 10 minutes.
I avoid sitting because it increases pain.
Revised Oswestry Low Back Pain Questionnaire
Fairbank J, Davies J, et al. The Oswestry Back Pain Disability
Questionnaire. Physiotherapy 1980;66(18):271-273.
Updated 02/09