Modified Oswestry Low Back Disability Index Form

Please Do Not Print This Form. Thank you for completing this patient-reported outcome questionnaire. Your responses help your provider determine the best treatment options to track your recovery progress over time. Please answer each of the questions included on this form.

ALL QUESTIONS MUST BE ANSWERED

Name *

First

Middle

Last

Date

Did you have surgery for this issue PRIOR TO receiving Physical Therapy? *

Yes
No

PAIN SCORE: Over the past 24 hours, how bad has your pain been? *

Select the number that best describes your pain. 0 = No Pain, 10 = Worst Pain imaginable.

1. PAIN INTENSITY: *

I can tolerate the pain I have without using pain medication.
The pain is bad, but I can manage without having to take pain medication.
Pain medication provides me with complete relief from pain.
Pain medication provides me with moderate relief from pain.
Pain medication has no effect on me.

2. PERSONAL CARE (WASHING, DRESSING, ETC.): *

I can take care of myself normally without causing increased pain.
I can take care of myself normally, but it increases my pain.
It is painful to take care of myself, and I am slow and careful.
I need some help, but I am able to manage most of my personal care.
I need help every day in most aspects of my care.
I do not get dressed, wash with difficulty, and stay in bed.

3. LIFTING: *

I can lift heavy weights without increased pain.
I can lift heavy weights, but it causes increased pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (e.g. on the 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.

4. WALKING: *

Pain does not prevent me from walking any distance.
Pain prevents me from walking more than 1 mile.
Pain prevents me from walking more than 1/2 mile.
Pain prevents me from walking more than 1/4 mile.
I can only walk with crutches or a cane.
I am in be most of the time and have to crawl to the toilet.

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 one hour.
Pain prevents me from sitting more than 30 minutes.
Pain prevents me from sitting more than 10 minutes.
Pain prevents me from sitting at all.

6. STANDING: *

I can stand as long as I want without increased pain.
I can stand as long as I want, but it increases my pain.
Pain prevents me from standing for more than one hour.
Pain prevents me from standing more than 30 minutes.
Pain prevents me from standing more than 10 minutes.
Pain prevents me from standing at all.

7. SLEEPING: *

Pain does not prevent me from sleeping well.
I can sleep well only by using pain medication.
Even when I take medication, I sleep less than 6 hours.
Even when I take medication, I sleep less than 4 hours.
Even when I take medication, I sleep less than 2 hours.
Pain prevents me from sleeping at all.

8. SOCIAL LIFE: *

My social life is normal and does not increase my pain.
My social life is normal, but it increases my level of pain.
Pain prevents me from participating in more energetic activities (e.g. sports, dancing, etc.).
Pain prevents me from going out very often.
Pain has restricted my social life to my home.
I have hardly any social life because of my pain.

9. TRAVELING *

I can travel anywhere without increased pain.
I can travel anywhere, but it increases my pain.
My pain restricts my travel over 2 hours.
My pain restricts my travel over 1 hour.
My pain restricts my travel to short necessary journeys under 1/2 hour.
My pain prevents all travel except for visits to the physician/therapist or hospital.

10. EMPLOYMENT/HOMEMAKING *

My normal homemaking/job activities do not cause pain.
My normal homemaking/job activities increase my pain, but I can still perform all that is required of me.
I can perform most of my normal homemaking/job activities, 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 chores.