Patient Form
OSWESTRY LOW BACK PAIN QUESTIONNAIRE
Innovative Physical Therapy LLC
Name:
*
First
Last
Occupation:
How long have you had back pain?
years
months
weeks
How long have you had leg pain?
years
months
weeks
PLEASE READ: 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, & mark in each one only the one box which applies to you.
Section 1: Pain Intensity
I can tolerate the pain I have without having to use pain killers
The pain is bad but I manage without taking pain killers
Pain killers give complete relief from pain
Pain killers give moderate relief from pain
Pain killers give very little relief from pain
Pain killers have no effect on the pain and I do not use them
Section 2: Personal Care (Washing, Dressing, Etc.)
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
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, but I can manage if they are conveniently positioned, eg. 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
I cannot lift or carry anything
Section 4: Walking
Pain does not prevent me walking any distance
Pain prevents me walking more than 1 mile
Pain prevents me walking more than 1/2 mile
Pain prevents me walking more than 1/4 mile
I can only walk using a stick 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 more than 1 hour
Pain prevents me from sitting more than 1/2 hour
Pain prevents me from sitting more than 10 minutes
Pain prevents me from sitting at all
Section 6: Standing
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 for more than 1 hour
Pain prevents me from standing for more than 1/2 hour
Pain prevents me from standing for more than 10 minutes
Pain prevents me from standing at all
Section 7: Sleeping
Pain does not prevent me from sleeping well
I can sleep well only by using tablets
Even when I take tablets I have less than six hours sleep
Even when I take tablets I have less than four hours sleep
Even when I take tablets I have less than two hours sleep
Pain prevents me from sleeping well at all
Section 8: Sex Life
My sex life is normal and causes no extra pain
My sex life is normal but causes some extra 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 pain
Pain prevents any sex life at all
Section 9: Social Life
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 significant effect on my social life apart from limiting my more energetic interests, eg dancing ETC
Pain has restricted social life and I do not go out as often
Pain has restricted social life to my home
I have no social life because of pain
Section 10: Traveling
I can travel anywhere without extra pain
I can travel anywhere but it gives me 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 journeys of less than 1/2 hour
Pain prevents me from traveling except to the doctor or hospital
Date:
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