Name: Advanced Spine, Sports & Rehab
Address: 806 W Main St, Atlanta, TX, 75551
Telephone: (903) 792-2060
Price range: $$

Oswestry Low Back Pain Disability Questionnaire

Clinician's name (or ref)

Patient's name (or ref)

This questionnaire has been designed to give your therapist information as to how your back pain has affected your ability to manage in everyday life. Please answer every question by placing a mark in the box that best describes your condition today.

During the past 4 weeks......

Section 1 - Pain Intensity		Section 6 - Standing
	I have no pain at the moment		I can stand as long as I want without extra pain.
	The pain is very mild at the moment		I can stand as long as I want but it extra my pain.
	The pain is moderate at the moment		Pain prevents me from standing for more than 1 hour.
	The pain is fairly severe at the moment		Pain prevents me from standing for more than½ an hour.
	The pain is very severe at the moment		Pain prevents me from standing for more than 10 minutes.
	The pain is the worst imaginable at the moment		Pain prevents me from standing at all.

Section 2 - Personal Care (e.g., Washing, Dressing)		Section 7 - Sleeping
	I can look after myself normally without causing extra pain		My sleep is never disturbed by pain.
	I can look after myself normally but it is very painful		My sleep is occasionally disturbed by pain.
	It is painful to look after myself and I am slow and careful		Because of pain I have less than 6 hours sleep.
	I need some help but manage most of my personal care		Because of pain I have less than 4 hours sleep.
	I need help every day in most aspects of self care		Because of pain I have less than 2 hours sleep.
	I do not get dressed, wash with difficulty and stay in bed		Pain prevents me from sleeping at all.

Section 3 - Lifting		Section 8 - Sex Life ( if applicable )
	I can lift heavy weights without extra pain		My sex life is normal and causes no extra pain.
	I can lift heavy weights but it gives extra pain		My sex life is normal but causes some extra pain.
	Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (e.g., on a table).		My sex life is nearly normal but is very painful.
	Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.		My sex life is severely restricted by pain.
	I can lift only very light weights.		My sex life is nearly absent because of pain.
	I cannot lift or carry anything at all.		Pain prevents any sex life at all

Section 4 - Walking		Section 9 - Social Life
	Pain does not prevent me from walking any distance.		My social life is normal and causes me no extra pain.
	Pain prevents me from walking more than 1 mile. (1 mile = 1.6 km)		My social life is normal, but increases the degree of pain.
	Pain prevents me from walking more than 1/4 mile.		Pain has no significant effect on my social life apart from limiting my more energetic interests (e.g., sports, dancing).
	Pain prevents me from walking more than 100 yards.		Painhas restricted my social life and I do not go out as often.
	I can walk only with crutches or a stick.		Pain has restricted my social life to my home.
	I am in bed most of the time and have to crawl to the toilet.		I have no social life because of my pain.

Section 5 - Sitting		Section 10 - Traveling
	I can sit in any chair as long as I like		I can travel anywhere without pain.
	I can sit in my favourite chair for as long as I like		I can travel anywhere, but it gives extra pain.
	Pain prevents me from sitting for more than 1 hour.		Pain is bad but I mangage journeys of over 2 hours.
	Pain prevents me from sitting for more than ½ an hour		Pain restricts me to journeys of less than 1 hour.
	Pain prevents me from sitting for more that 10 minutes		Pain restricts me to short necessary journeys under 30 minutes
	Pain prevents me from sitting at all.		Pain prevents me from travelling except to recieve treatment

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