OSWESTRY DISABILITY QUESTIONNAIRE

OSWESTRY DISABILITY QUESTIONNAIRE
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please Read: This questionnaire is designed to give us information as to how your back or leg pain has affected your ability to manage everyday life. Please answer each section and mark the ONE box that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just mark the one choice which closely describes your problem.
Section 1 - Pain Intensity
Section 2 - Personal Care (Washing, Dressing, etc.)
Section 3 - Lifting
Section 4 - Walking
Section 5 - Sitting
Section 6 - Standing
Section 7 - Sleeping
Section 8 - Sex life (if applicable)
Section 9 - Social Life
Section 10 - Traveling
GPSW Pain Diagram
Draw on Image
Should be Empty: