"Oswestry Disability Index Questionnaire Template"

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Oswestry Disability Index
This questionnaire has been designed to give the doctor information as to how your pain or condition has affected your ability to
manage everyday life. Please answer every section and circle in each section only the ONE number that applies to you. We realize
that you may consider that two of the statements in any one section relate to you, but please just circle the number that most closely
describes your problem.
Section 1: Pain Intensity
Section 6: Standing
0.
The pain comes and goes and is very mild.
0.
I can stand as long as I want without pain.
1.
The pain is mild and does not vary much.
1.
I have some pain on standing, but it does not increase
2.
The pain comes and goes and is moderate.
with time.
3.
The pain is moderate and does not vary much.
2.
I cannot stand for longer than one hour without increasing
4.
The pain comes and goes and is very severe.
pain.
5.
The pain is severe and does not vary much.
3.
I cannot stand for longer than 1/2 hour without increasing
pain.
Section 2: Personal Care
4.
I cannot stand for longer than 10 minutes without
increasing pain.
0.
I would not have to change my way of washing or dressing
5.
I avoid standing because it increases the pain right away.
in order to avoid pain.
1.
I do not normally change my way of washing or dressing
even though it causes some pain.
Section 7: Sleeping
2.
Washing and dressing increases the pain, but I manage
0.
I get no pain in bed.
not to change my way of doing it.
1.
I get pain in bed, but it does not prevent me from sleeping
3.
Washing and dressing increases the pain and I find it
well.
necessary to change my way of doing it.
Because of pain, my normal night’s sleep is reduced by
2.
4.
Because of the pain, I am unable to do some washing and
less than 1/4.
dressing without help.
Because of pain, my normal night’s sleep is reduced by
3.
5.
Because of the pain, I am unable to do any washing and
less than 1/2.
dressing without help.
Because of pain, my normal night’s sleep is reduced by
4.
less than 3/4.
Section 3: Lifting
5.
Pain prevents me from sleeping at all.
0.
I can lift heavy weights without extra pain.
1.
I can lift heavy weights, but it causes extra pain.
Section 8: Social Life
2.
Pain prevents me from lifting heavy weights off the floor,
0.
My social life is normal and gives me no pain.
but I manage if they are conveniently positioned (e.g., on a
1.
My social life is normal, but increases the degree of pain.
table).
2.
Pain has no significant effect on my social life apart from
3.
Pain prevents me from lifting heavy weights off the floor.
limiting my more energetic interests, e.g., dancing, etc.
4.
Pain prevents me from lifting heavy weights, but I can
3.
Pain has restricted my social life and I do not go out very
manage light to medium weights if they are conveniently
often.
positioned.
4.
Pain has restricted my social life to my home.
5.
I can only lift very light weights at the most.
5.
I have hardly any social life because of the pain.
Section 4: Walking
Section 9: Traveling
0.
I have no pain on walking.
0.
I get no pain while travelling.
1.
I have some pain on walking, but it does not increase with
1.
I get some pain while travelling, but none of my usual
distance.
forms of travel makes it any worse.
2.
I cannot walk more than one mile without increasing pain.
2.
I get extra pain while travelling, but it does not compel me
3.
I cannot walk more than 1/2 mile without increasing pain.
to seek alternative forms of travel.
4.
I cannot walk more than 1/4 mile without increasing pain.
3.
I get extra pain while travelling, which compels me to seek
5.
I cannot walk at all without increasing pain.
alternative forms of travel.
4.
Pain restricts all forms of travel.
Section 5: Sitting
5.
Pain prevents all forms of travel except that done lying
0.
I can sit in any chair as long as I like.
down.
1.
I can only sit in my favorite chair as long as I like.
2.
Pain prevents me from sitting more than one hour.
Section 10: Changing Degree of Pain
3.
Pain prevents me from sitting more than 1/2 hour
0.
My pain is rapidly getting better.
4.
Pain prevents me from sitting more 10 minutes.
1.
My pain fluctuates, but is definitively getting better.
5.
I avoid sitting because it increases pain right away.
2.
My pain seems to be getting better, but improvement is
slow at present.
3.
My pain is neither getting better nor worse.
4.
My pain is gradually worsening.
5.
My pain is rapidly worsening.
0-10
Minimal disability
11-20
Moderate disability
Patient’s Signature:
21-30
Severe disability
31-40
Crippled (incapacitated)
____________________________________________________________________________
40-50
Bed-bound
Date:________________________________________________
Oswestry Disability Index
This questionnaire has been designed to give the doctor information as to how your pain or condition has affected your ability to
manage everyday life. Please answer every section and circle in each section only the ONE number that applies to you. We realize
that you may consider that two of the statements in any one section relate to you, but please just circle the number that most closely
describes your problem.
Section 1: Pain Intensity
Section 6: Standing
0.
The pain comes and goes and is very mild.
0.
I can stand as long as I want without pain.
1.
The pain is mild and does not vary much.
1.
I have some pain on standing, but it does not increase
2.
The pain comes and goes and is moderate.
with time.
3.
The pain is moderate and does not vary much.
2.
I cannot stand for longer than one hour without increasing
4.
The pain comes and goes and is very severe.
pain.
5.
The pain is severe and does not vary much.
3.
I cannot stand for longer than 1/2 hour without increasing
pain.
Section 2: Personal Care
4.
I cannot stand for longer than 10 minutes without
increasing pain.
0.
I would not have to change my way of washing or dressing
5.
I avoid standing because it increases the pain right away.
in order to avoid pain.
1.
I do not normally change my way of washing or dressing
even though it causes some pain.
Section 7: Sleeping
2.
Washing and dressing increases the pain, but I manage
0.
I get no pain in bed.
not to change my way of doing it.
1.
I get pain in bed, but it does not prevent me from sleeping
3.
Washing and dressing increases the pain and I find it
well.
necessary to change my way of doing it.
Because of pain, my normal night’s sleep is reduced by
2.
4.
Because of the pain, I am unable to do some washing and
less than 1/4.
dressing without help.
Because of pain, my normal night’s sleep is reduced by
3.
5.
Because of the pain, I am unable to do any washing and
less than 1/2.
dressing without help.
Because of pain, my normal night’s sleep is reduced by
4.
less than 3/4.
Section 3: Lifting
5.
Pain prevents me from sleeping at all.
0.
I can lift heavy weights without extra pain.
1.
I can lift heavy weights, but it causes extra pain.
Section 8: Social Life
2.
Pain prevents me from lifting heavy weights off the floor,
0.
My social life is normal and gives me no pain.
but I manage if they are conveniently positioned (e.g., on a
1.
My social life is normal, but increases the degree of pain.
table).
2.
Pain has no significant effect on my social life apart from
3.
Pain prevents me from lifting heavy weights off the floor.
limiting my more energetic interests, e.g., dancing, etc.
4.
Pain prevents me from lifting heavy weights, but I can
3.
Pain has restricted my social life and I do not go out very
manage light to medium weights if they are conveniently
often.
positioned.
4.
Pain has restricted my social life to my home.
5.
I can only lift very light weights at the most.
5.
I have hardly any social life because of the pain.
Section 4: Walking
Section 9: Traveling
0.
I have no pain on walking.
0.
I get no pain while travelling.
1.
I have some pain on walking, but it does not increase with
1.
I get some pain while travelling, but none of my usual
distance.
forms of travel makes it any worse.
2.
I cannot walk more than one mile without increasing pain.
2.
I get extra pain while travelling, but it does not compel me
3.
I cannot walk more than 1/2 mile without increasing pain.
to seek alternative forms of travel.
4.
I cannot walk more than 1/4 mile without increasing pain.
3.
I get extra pain while travelling, which compels me to seek
5.
I cannot walk at all without increasing pain.
alternative forms of travel.
4.
Pain restricts all forms of travel.
Section 5: Sitting
5.
Pain prevents all forms of travel except that done lying
0.
I can sit in any chair as long as I like.
down.
1.
I can only sit in my favorite chair as long as I like.
2.
Pain prevents me from sitting more than one hour.
Section 10: Changing Degree of Pain
3.
Pain prevents me from sitting more than 1/2 hour
0.
My pain is rapidly getting better.
4.
Pain prevents me from sitting more 10 minutes.
1.
My pain fluctuates, but is definitively getting better.
5.
I avoid sitting because it increases pain right away.
2.
My pain seems to be getting better, but improvement is
slow at present.
3.
My pain is neither getting better nor worse.
4.
My pain is gradually worsening.
5.
My pain is rapidly worsening.
0-10
Minimal disability
11-20
Moderate disability
Patient’s Signature:
21-30
Severe disability
31-40
Crippled (incapacitated)
____________________________________________________________________________
40-50
Bed-bound
Date:________________________________________________
Oswestry Disability Index Form Disability Forms Legal

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