[%PracticeInfo%]	Oswestry Low Back Questionnaire

Patient name:______________________________  Signature:_____________________________  Date: __________

This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box which MOST CLOSELY describes your problem.

Section 1 – Pain Intensity
􀂆 The pain comes and goes and is very mild.
􀂆 The pain is mild and does not vary much.
􀂆 The pain comes and goes and is moderate.
􀂆 The pain is moderate and does not vary much.
􀂆 The pain comes and goes and is severe.
􀂆 The pain is severe and does not vary much.

Section 2 – Personal Care (Washing, Dressing, etc.)
􀂆 I would not have to change my way of washing or dressing in order to avoid pain.
􀂆 I do not normally change my way of washing or dressing even though it causes some pain.
􀂆 Washing and dressing increase the pain but I manage not to change my way of doing it.
􀂆 Washing and dressing increase the pain and I find it necessary to change my way of doing it.
􀂆 Because of the pain I am unable to do some washing and dressing without help.
􀂆 Because of the pain I am unable to do any washing and dressing without help.

Section 3 – Lifting
􀂆 I can lift heavy weights without extra pain.
􀂆 I can lift heavy weights but it gives extra pain.
􀂆 Pain prevents me from lifting heavy weights off the floor.
􀂆 Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned, e.g. on a table.
􀂆 Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned.
􀂆 I can only lift very light weights at the most.

Section 4 – Walking
􀂆 I have no pain on walking.
􀂆 I have some pain with walking but it does not increase with distance.
􀂆 I cannot walk more than One Mile without increasing pain.
􀂆 I cannot walk more than 1/2 Mile without increasing pain.
􀂆 I cannot walk more than 1/4 Mile without increasing pain.
􀂆 I cannot walk at all without increasing pain.

Section 5 – Sitting
􀂆 I can sit in any chair as long as I like.
􀂆 I can only sit in my favorite chair as long as I like.
􀂆 Pain prevents me from sitting more than one hour.
􀂆 Pain prevents me from sitting more than 30 minutes.
􀂆 Pain prevents me from sitting more than 10 minutes.
􀂆 I avoid sitting because it increases pain straight away.

Section 6 – Standing
􀂆 I can stand as long as I want without pain.
􀂆 I have some pain on standing but it does not increase with time.
􀂆 I cannot stand for longer than one hour without increasing pain.
􀂆 I cannot stand for longer than 1/2 hour without increasing pain.
􀂆 I cannot stand for longer than 10 minutes without increasing pain.
􀂆 I avoid standing because it increases pain straight away.

Section 7 – Sleeping
􀂆 I get no pain in bed.
􀂆 I get pain in bed but it does not prevent me from sleeping well.
􀂆 Because of pain my normal nights sleep is reduced by less than 1/4.
􀂆 Because of pain my normal nights sleep is reduced by less than 1/2.
􀂆 Because of pain my normal nights sleep is reduced by less than 3/4.
􀂆 Pain prevents me from sleeping at all.

Section 8 – Social Life
􀂆 My social life is normal and gives me no pain.
􀂆 My social life is normal but increases the degree of my pain.
􀂆 Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing, etc.
􀂆 Pain has restricted my social life and I do not go out very often.
􀂆 Pain has restricted social life to my home.
􀂆 I have hardly any social life because of the pain.

Section 9 – Traveling
􀂆 I get no pain while traveling.
􀂆 I get some pain while traveling but none of my usual sorts of travel make it any worse.
􀂆 I get extra pain while traveling but it does not compel me to seek alternative forms of travel.
􀂆 I get extra pain while traveling which compels me to seek alternative forms of travel.
􀂆 Pain restricts all forms of travel.
􀂆 Pain prevents all forms of travel except that done lying down.

Section 10 – Changing Degree of Pain
􀂆 My pain is rapidly getting better.
􀂆 My pain fluctuates but overall is definitely getting better.
􀂆 My pain seems to be getting better but improvement is slow
at the present.
􀂆 My pain is neither getting better or worse.
􀂆 My pain is gradually worsening.
􀂆 My pain is rapidly worsening.