Oswestry Disability Index

Patient Name*

DOB*

Today's Date*

Oswestry Disability Index - 2.1a

This questionnaire has been designed to give us information as to how your back (or leg) trouble affects your ability lo manage in everyday life. Please answer every section. Mark one box only in each section that most closely describes you today.

Section 1 - Pain Intensity*

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 worst imaginable at the moment.

Section 2 - Personal Care (washing, dressing, etc.)*

I can look after myself normally without causing additional pain.

I can look after myself normally but it is very painful.

lt 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 my personal care.

I do not get dressed, I wash with difficulty and stay in bed.

Section 3 - Lifting*

I can lift heavy weights without additional pain.

I can lift heavy weights but it gives additional pain.

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 lift only very light weights.

I cannot lift or carry anything at all.

Section 4 - Walking*

Pain does not prevent me from walking any distance.

Pain prevents me from walking more than one mile.

Pain prevents me from walking more than a quarter of a mile.

Pain prevents me from walking more than 100 yards.

I can only walk using a cane or crutches.

I am in bed most of the time and have to crawl to the toilet.

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 for more than one hour.

Pain prevents me from sitting for more than half an hour.

Pain prevents me from sitting for more than 10 minutes.

Pain prevents me from silting at all.

Section 6 - Standing*

I can stand as long as I want without additional pain.

I can stand as long as I want but it gives me additional pain.

Pain prevents me from standing for more than 1 hour.

Pain prevents me from standing for more than half an hour.

Pain prevents me from standing for more than 10 minutes.

Pain prevents me from standing at all.

Section 7 - Sleeping*

My sleep is never interrupted by pain.

My sleep is occasionally interrupted 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.

Section 8 - Sex Life (If applicable)*

My sex life is normal and causes no additional pain.

My sex life is normal but causes some additional pain.

My sex life is nearly normal but is very painful.

My sex life is severely restricted by pain.

My sex life is nearly non existent because of pain.

Pain prevents me from having any sex life at all.

Section 9 - Social Life*

My social life is normal and causes me no additional 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. sports, etc.

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.

Section 10 -Traveling*

I can travel anywhere without pain.

I can travel anywhere but it gives me additional pain.

Pain is bad but I am able to manage trips over two hours.

Pain restricts me to trips of less than one hour.

Pain restricts me to short necessary journeys under 30 minutes.

Pain prevents traveling except to receive treatment.

Phone

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Oswestry Disability Index - 2.1a

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