ࡱ> []Zq` MbjbjqPqP 7P::VVVVVVVj<j xh4$h$9V$VV]VVVV #mPiF2bs0 H  Vp$$ jjjd DjjjjjjVVVVVV Office Use: Therapist:______ The Oswestry Low Back Pain Disability Index (Confidential) Score: ________ Patient Name:  FORMTEXT       Date: FORMTEXT       Please check only ONE statement in each section that describes how youre feeling TODAY Section 1 Pain Intensity  FORMCHECKBOX  My pain is mild to absent; I do not need pain killers.  FORMCHECKBOX  The pain is moderate, but I manage without taking pain killers.  FORMCHECKBOX  Pain killers give me complete relief from pain.  FORMCHECKBOX  Pain killers give me moderate relief from pain.  FORMCHECKBOX  Pain killers give me very little relief from pain.  FORMCHECKBOX  Pain killers have no effect on the pain.Section 6 Standing  FORMCHECKBOX I can stand as long as I want without extra pain.  FORMCHECKBOX I can stand as long as I want, but it gives me extra pain.  FORMCHECKBOX Pain prevents me from standing more than one hour.  FORMCHECKBOX Pain prevents me from standing more than 30 minutes.  FORMCHECKBOX Pin prevents me from standing more than 10 minutes.  FORMCHECKBOX Pain prevents me from standing at all.Section 2 Personal Care (Washing, Dressing, etc)  FORMCHECKBOX  I can look after myself normally without causing extra pain.  FORMCHECKBOX  I can look after myself normally but it causes extra pain.  FORMCHECKBOX  It is painful to look after myself and I am slow and careful.  FORMCHECKBOX  I need some help but manage most of my personal care.  FORMCHECKBOX  I need help everyday in most aspects of self-care.  FORMCHECKBOX  I do not get dressed. I wash with difficulty and stay in bed.Section 7 Bending  FORMCHECKBOX I can bend without extra pain.  FORMCHECKBOX I can bend, but it gives me some extra pain.  FORMCHECKBOX I can bend, but it is very painful.  FORMCHECKBOX My bending is severely restricted by pain.  FORMCHECKBOX My bending is nearly absent because of pain.  FORMCHECKBOX Pain prevents me from bending.Section 3 Lifting/Pushing (Vacuuming, Mowing, Shoveling)  FORMCHECKBOX I can lift/push heavy items without extra pain.  FORMCHECKBOX I can lift/push heavy items but it gives extra pain.  FORMCHECKBOX I can lift/push heavy items if conveniently positioned.  FORMCHECKBOX I can lift/push light items if conveniently positioned.  FORMCHECKBOX I can lift/push only very light weight items.  FORMCHECKBOX  I cannot lift/push anything at all.Section 8 Social Life  FORMCHECKBOX My social life is normal and causes me no extra pain.  FORMCHECKBOX My social life is normal but, but increases the degree of pain.  FORMCHECKBOX Pain limits me from my more energetic interests (dancing, etc).  FORMCHECKBOX Pain has restricted my social life and I do not go out as often.  FORMCHECKBOX Pain has restricted my social life to my home.  FORMCHECKBOX I have no social life because of pain.Section 4 Walking  FORMCHECKBOX I can walk as far as I want.  FORMCHECKBOX Pain prevents me walking more than one mile.  FORMCHECKBOX Pain prevents me walking more than mile.  FORMCHECKBOX Pain prevents me walking more than mile.  FORMCHECKBOX I can walk only if I use a stick or crutches.  FORMCHECKBOX I am in bed or in a chair for majority of everyday.Section 9 Sleeping  FORMCHECKBOX Pain does not prevent me from sleeping well.  FORMCHECKBOX I sleep well, but only by using tablets  FORMCHECKBOX I have less than six hours sleep.  FORMCHECKBOX I have less than four hours sleep.  FORMCHECKBOX I have less than two hours sleep.  FORMCHECKBOX Pain prevents me from sleeping at all.Section 5 Sitting  FORMCHECKBOX I can sit in any chair as long as I like.  FORMCHECKBOX I can sit in my favorite chair only, but for as long as I like.  FORMCHECKBOX Pain prevents me from sitting more than one hour.  FORMCHECKBOX Pain prevents me from sitting more than hour.  FORMCHECKBOX Pain prevents me from sitting more than 10 minutes.  FORMCHECKBOX Pain prevents me from sitting at all.Section 10 - Traveling  FORMCHECKBOX I can travel anywhere without extra pain.  FORMCHECKBOX I can travel anywhere, but it gives me extra pain.  FORMCHECKBOX Pain is bad, but I manage journeys over two hours.  FORMCHECKBOX Pain restricts me to journeys of less than one hour.  FORMCHECKBOX Pain restricts me to short journeys of less than 30 minutes.  FORMCHECKBOX Pain prevents me from traveling, except to the doctor or hospital. 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