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Low Back Index

Low Back Index

LOW BACK PAIN AND DISABILITY QUESTIONNAIRE
(Revised Oswestry)

Name*

Phone *

Date *

PLEASE READ THE INSTRUCTIONS:

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 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 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 me 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, for example 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 most

Section 4 – WALKING

I have no pain on walking. I have some pain on walking but it does not increase with distance. I cannot walk more than one km without increasing pain. I cannot walk more than ½ km without increasing pain. I cannot walk more than ¼ km without increasing pain. I cannot walk without increasing pain at all.

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 half an hour. Pain prevents me from sitting more than ten 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 ½ hour without increasing pain. I cannot stand for longer than ten minutes without increasing pain. I avoid standing because it increases the 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 night’s sleep is reduced by less than ¼ of an hour. Because of pain my normal night’s sleep is reduced by less than ½ of an hour. Because of pain my normal night’s sleep is reduced by less than ¾ of an hour. 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 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 my social life to my home. I have hardly any social life because of the pain.

Section 9 –TRAVELLING

I get no pain while travelling. I get some pain while travelling but none of my usual forms of travel make it any worse. I get extra pain while travelling but it does not compel me to seek alternative forms of travel. I get extra pain while travelling which compels me to seek alternative forms of travel. Pain restricts all forms of travel. Pain restricts 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 present. My pain is neither getting better or worse. My pain is gradually worsening. My pain is rapidly worsening.

PAIN SCALE:

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Douglas P Krift DC

Address

1467 S Ft Thomas Ave
Fort Thomas, KY 41075

Contact Information (859) 781-8700

[email protected]

Office Hours

Monday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday

Closed

Wednesday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Thursday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Friday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Saturday

Closed

Sunday

Closed

1467 S Ft Thomas Ave
Fort Thomas, KY 41075

(859) 781-8700

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Low Back Index

LOW BACK PAIN AND DISABILITY QUESTIONNAIRE (Revised Oswestry)

Location

Find us on the map

Office Hours

LOW BACK PAIN AND DISABILITY QUESTIONNAIRE
(Revised Oswestry)