Modified Oswestry Low Back Pain Questionnaire

1
Name* This field is required.
First Name
Last Name
2
Date* This field is required.
Date
Day
Month
Year
3
Section 1 / 10 - Pain Intensity* This field is required.
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
4
Section 2 / 10 - Personal Care* This field is required.
I do not have to change my way of washing or dressing to avoid pain
I do not normally change my way of washing or dressing even though it causes me pain
Washing and dressing increase the pain, but I manage not to change my way of doing it
Washing and dressing increases that 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
5
Section 3 / 10 - Lifting* This field is required.
I can lift heavy weights without extra low back pain
I can lift heavy weights but it causes extra pain
Pain prevents me lifting heavy weights off the floor
Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently positioned e.g on a table
Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned
I can only lift light weights at the most
6
Section 4 / 10 - Walking* This field is required.
I have no pain walking
I have some pain on walking, but I can still walk my required to normal distances
Pain prevents me from walking long distances
Pain prevents me from walking intermediate distances
Pain prevents me from walking even short distances
Pain prevents me from walking at all
7
Section 5 / 10 - Sitting* This field is required.
Sitting does not cause me any pain
I can sit as long as I need provided I have my choice of sitting surfaces
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
8
Section 6 / 10 - Standing* This field is required.
I can stand as long as I want without pain
I have some pain while standing, but it does not increase with time
I cannot stand for longer than 1 hour without increasing pain
I cannot stand for longer than 1/2 hour without increasing pain
I cannot stand for longer than 10 minutes without increasing pain
I avoid standing because it increases the pain immediately
9
Section 7 / 10 - Sleeping* This field is required.
I have no pain while in bed
I have pain in bed, but it does not prevent me from sleeping well
Because of pain, I sleep only 3/4 of normal time
Because of pain, I sleep 1/2 of normal time
Because of pain, I sleep 1/4 of normal time
Pain prevents me from sleeping at all
10
Section 8 / 10 - Social Life* This field is required.
My social life is normal and gives me no pain
My social life is normal, but increases the degree of pain
Pain prevents me from participating in more energetic activities e.g sports, dancing.
Pain prevents me from going out very often
Pain has restricted my social life to my home
I hardly have any social life because of pain
11
Section 9 / 10 - Traveling* This field is required.
I get no pain while traveling
I get some pain while traveling, but none of my usual forms of travel make it any worse
I get some pain while traveling, but it does not compel me to seek alterative forms of travel
I get extra pain while traveling that requires me to seek alternative forms of travel
Pain restricts all forms of travel
Pain prevents all forms of travel except that done lying down
12
Section 10/ 10 - Employment/House making* This field is required.
My normal job/house making duties do not cause pain
My normal job/house making duties cause me extra pain, but I can still perform all that is required of me
I can perform most of my job/house making duties, but pain prevents me from performing more physically stressful activities e.g lifting, vacuuming etc
Pain prevents me from doing anything but light duties
Pain prevents me from doing even light duties
Pain prevents me from performing any job or homemaking chore
13
Total Score PercentageScore Each Section 0-5 & TOTAL. Then DOUBLE to get %. Interpretation: * 0-20% Minimal Disability * 20-40% Moderate Disability * 40-60% Severe Disability * 60-80% Crippled * 80-100% Bed-bound
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