Oswestry Low Back Pain Disability Questionnaire

Name*
Name
First Last
Please select your case manager*
Please select your case manager

Section 1: Pain Intensity*
Section 1: Pain Intensity (Please select the answer that most closely identifies your situation)
- I have no pain at the moment
- The pain is very mild at the moment
- The pain is moderate at the moment
- The pain is fairly severe at the moment
- The pain is very severe at the moment
- The pain is the worst imaginable at the moment
Please describe how your pain intensity affects your daily life activities*
Please describe how your pain intensity affects your daily life activities

Section 2: Personal Care (Washing, Dressing, etc.)*
Section 2: Personal Care (Washing, Dressing, etc.) (Please select the answer that most closely identifies your situation)
- I can look after myself normally without causing extra pain.
- I can look after myself normally, but it causes extra pain.
- It is painful to look after myself and I am slow and careful.
- I need some help, but manage most of my personal care.
- I need help every day in most aspects of self-care.
- I do not get dressed, wash with difficulty, and stay in bed.
Please describe how your low back injury has affected your ability to address your personal care*
Please describe how your low back injury has affected your ability to address your personal care

Section 3: Lifting*
Section 3: Lifting (Please select the answer that most closely identifies your situation)
- I can lift heavy weights without extra pain.
- I can lift heavy weights, but it causes extra pain.
- Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned.
- Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.
- I can lift only very light weights.
- I cannot lift or carry anything at all.
Please describe how your difficulty lifting affects your daily life*
Please describe how your difficulty lifting affects your daily life

Section 4: Walking*
Section 4: Walking (Please select the answer that most closely identifies your situation)
- Pain does not prevent me walking any distance.
- Pain prevents me from walking for more than 1 mile.
- Pain prevents me from walking for more than 1/2 mile.
- Pain prevents me from walking more than 100 yards.
- I can only walk using a stick or crutches.
- I am in bed most of the time and have to crawl to the toilet.
Please describe how your difficulty walking affects your daily life*
Please describe how your difficulty walking affects your daily life

Section 5: Sitting*
Section 5: Sitting (Please select the answer that most closely identifies your situation)
- I can sit in any chair as long as I like.
- I can sit in my favorite chair as long as I like.
- Pain prevents me from sitting for more than 1 hour.
- Pain prevents me from sitting for more than ½ hour.
- Pain prevents me from sitting for more than 10 minutes.
- Pain prevents me from sitting at all.
Please describe how your difficulty sitting affects your daily life activities*
Please describe how your difficulty sitting affects your daily life activities

Section 6: Standing*
Section 6: Standing (Please select the answer that most closely identifies your situation)
- I can stand as long as I want without extra pain
- I can stand as long as I want, but it gives me extra pain
- Pain prevents me from standing more than 1 hour
- Pain prevents me from standing for more than ½ hour
- Pain prevents me from standing for more than 10 minutes
- Pain prevents me from standing at all
Please describe how your difficulty standing affects your daily life*
Please describe how your difficulty standing affects your daily life

Section 7: Sleeping*
Section 7: Sleeping (Please select the answer that most closely identifies your situation)
- My sleep is never disturbed by pain
- My sleep is occasionally disturbed by pain
- Because of pain I have less than 6 hours sleep
- Because of pain I have less than 4 hours sleep
- Because of pain I have less than 2 hours sleep
- Pain prevents me from sleeping at all
Please describe how your difficulty sleeping affects your daily life*
Please describe how your difficulty sleeping affects your daily life

Section 8: Sex Life
Section 8: Sex Life (Please select the answer that most closely identifies your situation) (This question is not required)
- My sex life is normal and causes no extra pain
- My sex life is normal, but causes some pain
- My sex life is nearly normal, but is very painful
- My sex life is severely restricted by pain
- My sex life is nearly absent because of back pain
- I have no sex life because of pain
Please describe how your low back injury affects your sex life*
Please describe how your low back injury affects your sex life

Section 9: Social Life*
Section 9: Social Life (Please select the answer that most closely identifies your situation)
- My social life is normal and gives me no extra pain
- My social life is normal, but increases the degree of pain
- Pain has no effect on my social life apart from limiting my more energetic interests
- Pain has restricted my social life and I do not go out as often
- Pain has restricted my social life to my home
- I have no social life because of pain
Please describe how your low back injury affects your daily social life*
Please describe how your low back injury affects your daily social life

Section 10: Travel*
Section 10: Travel (Please select the answer that most closely identifies your situation)
- I can travel anywhere without extra pain
- I can travel anywhere, but it gives extra pain
- Pain is bad, but I manage journeys over two hours
- Pain restricts me to journeys of less than one hour
- Pain restricts me to short necessary journeys less than 30 minutes
- Pain prevents me from traveling except to receive treatment
Please describe how your difficulty low back injury affects your ability to travel*
Please describe how your difficulty low back injury affects your ability to travel

Lumbar radiculopathy is pain that spreads into the buttocks and legs and can be associated when lower back trauma occurs. Please select any of the symptoms below that you have experienced. (Select all that apply)*
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)
- Muscle weakness in the hips, buttocks, legs, ankles and/or feet
- Numbness in the hips, buttocks, legs, ankles and/or feet
- Tingling in the hips, buttocks, legs, ankles and/or feet
- Pain in the hips, buttocks, legs, ankles and/or feet
- Lack of coordination in the legs and/or feet
For the areas you checked for lumbar radiculopathy, please give details as to what you are experiencing*
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*
Please select any areas where your life has been affected by your low back injury
- Work Duties
- Studies/Educational Duties
- Domestic Duties
- Household Duties
- Hobbies
- Sports
- Travel

Are you taking medication for your low back injury?*
Are you taking medication for your low back injury?
- Yes
- No

Medication Name*
Medication Name
How long have you been taking this medication?*
How long have you been taking this medication?
How often do you take this medication?*
How often do you take this medication?
Less than once per week Once per week 1-2 days per week Most days per week Daily Multiple times daily
Are you taking any additional medication for your low back injury?*
Are you taking any additional medication for your low back injury?
- Yes
- No
Medication Name*
Medication Name
How long have you been taking this medication?*
How long have you been taking this medication?
How often do you take this medication?*
How often do you take this medication?
Less than once per week Once per week 1-2 days per week Most days per week Daily Multiple times daily
Are you taking any additional medication for your low back injury?-*
Are you taking any additional medication for your low back injury?
- Yes
- No
Medication Name*
Medication Name
How long have you been taking this medication?*
How long have you been taking this medication?
How often do you take this medication?*
How often do you take this medication?
Less than once per week Once per week 1-2 days per week Most days per week Daily Multiple times daily

Oswestry Low Back Pain Disability Questionnaire

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