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Oswestry Low Back Pain Disability QuestionnaireJared Larsen2020-09-28T21:38:57+00:00

Oswestry Low Back Pain Disability Questionnaire

This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by selecting ONE answer in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem.

Step 1 of 15

6%
  • Name
  • Please select your case manager
  • Section 1: Pain Intensity (Please select the answer that most closely identifies your situation)
  • Please describe how your pain intensity affects your daily life activities
  • Section 2: Personal Care (Washing, Dressing, etc.) (Please select the answer that most closely identifies your situation)
  • Please describe how your low back injury has affected your ability to address your personal care
  • Section 3: Lifting (Please select the answer that most closely identifies your situation)
  • Please describe how your difficulty lifting affects your daily life
  • Section 4: Walking (Please select the answer that most closely identifies your situation)
  • Please describe how your difficulty walking affects your daily life
  • Section 5: Sitting (Please select the answer that most closely identifies your situation)
  • Please describe how your difficulty sitting affects your daily life activities
  • Section 6: Standing (Please select the answer that most closely identifies your situation)
  • Please describe how your difficulty standing affects your daily life
  • Section 7: Sleeping (Please select the answer that most closely identifies your situation)
  • Please describe how your difficulty sleeping affects your daily life
  • Section 8: Sex Life (Please select the answer that most closely identifies your situation) (This question is not required)
  • Please describe how your low back injury affects your sex life
  • Section 9: Social Life (Please select the answer that most closely identifies your situation)
  • Please describe how your low back injury affects your daily social life
  • Section 10: Travel (Please select the answer that most closely identifies your situation)
  • Please describe how your difficulty low back injury affects your ability to travel
  • Lumbar radiculopathy is pain that spreads into the hips, buttocks, legs, ankles and/or feet and can be associated when lower back trauma occurs. Please select any of the symptoms below that you have experienced. (Select all that apply)
  • For the areas you checked for lumbar radiculopathy, please give details as to what you are experiencing
  • Please select any areas where your life has been affected by your low back injury
  • Are you taking medication for your low back injury?
  • Medication Name
  • How long have you been taking this medication?
  • How often do you take this medication?
    Less than once per weekOnce per week1-2 days per weekMost days per weekDailyMultiple times daily
  • Are you taking any additional medication for your low back injury?
  • Medication Name
  • How long have you been taking this medication?
  • How often do you take this medication?
    Less than once per weekOnce per week1-2 days per weekMost days per weekDailyMultiple times daily
  • Are you taking any additional medication for your low back injury?
  • Medication Name
  • How long have you been taking this medication?
  • How often do you take this medication?
    Less than once per weekOnce per week1-2 days per weekMost days per weekDailyMultiple times daily

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