ࡱ> []Zq` IbjbjqPqP 7L::VVVVVVVj2222|<jm  $Y!h#-V@@@VV' @ VV@VV `3aiF2J 8= 0m W$TzW$W$V`0"&B m @@@@jjjd djjjjjjVVVVVV Office Use: Therapist:______ The Oswestry Lower Extremity 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  I have no pain at the moment.  FORMCHECKBOX  Pain is very mild at the moment.  FORMCHECKBOX  Pain is moderate at the moment.  FORMCHECKBOX  Pain is fairly severe at the moment.  FORMCHECKBOX  Pain is very severe at the moment.  FORMCHECKBOX  Pain is the worst imaginable at the moment.Section 6 Range of Motion  FORMCHECKBOX I have full range of motion in my leg(s).  FORMCHECKBOX I have 75% of range of motion in my leg(s).  FORMCHECKBOX I have 50% of range of motion in my leg(s).  FORMCHECKBOX I have 25% of range of motion in my leg(s).  FORMCHECKBOX I can move my leg(s) with assistance.  FORMCHECKBOX I cannot move my leg(s) 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 increases the degree of pain.  FORMCHECKBOX  It is moderately painful to look after myself.  FORMCHECKBOX  Pain is fairly severe when I look after myself; I am slow & careful.  FORMCHECKBOX  I need some help but manage most of my personal care.  FORMCHECKBOX  I do not get dressed. I wash with difficulty and stay in bed.Section 7 Strength  FORMCHECKBOX I have normal strength in my leg(s).  FORMCHECKBOX My strength is about 75% of my normal strength.  FORMCHECKBOX My strength is about 50% of my normal strength.  FORMCHECKBOX My strength is about 25% of my normal strength.  FORMCHECKBOX My leg strength is greatly restricted.  FORMCHECKBOX I have no strength in my leg(s).Section 3 Ambulation  FORMCHECKBOX I can walk as far as I want without difficulty.  FORMCHECKBOX I can walk as far as I want but have mild difficulty.  FORMCHECKBOX My walking distance is moderately limited.  FORMCHECKBOX My walking distance is moderately limited: I need an assistive device.  FORMCHECKBOX My walking distance is severely limited: I need an assistive device.  FORMCHECKBOX  I am unable to walk at all.Section 8 Driving  FORMCHECKBOX I can drive my car without any pain.  FORMCHECKBOX I can drive my car as desired with mild pain.  FORMCHECKBOX I can drive my car as desired with moderate pain.  FORMCHECKBOX I cannot drive my car more than hour because of fairly severe pain.  FORMCHECKBOX I can only drive my car for 15 minutes or less because of severe pain.  FORMCHECKBOX I cannot drive my car at all.Section 4 Stair Climbing  FORMCHECKBOX I can go up and down stairs without difficulty.  FORMCHECKBOX I have mild difficulty going up and down stairs.  FORMCHECKBOX I have moderate difficulty going up and down stairs.  FORMCHECKBOX I have moderate difficulty and use support going up & down stairs.  FORMCHECKBOX My stair climbing is severely limited; I need help up & down stairs.  FORMCHECKBOX I am unable to go up and down stairs at all.Section 9 - Sleeping  FORMCHECKBOX Pain does not prevent me from sleeping well.  FORMCHECKBOX I sleep well, but occasionally wake with pain.  FORMCHECKBOX I take tablets and still sleep less than six hours.  FORMCHECKBOX I take tablets and still sleep less than four hours.  FORMCHECKBOX I take tablets and still sleep less than two hours.  FORMCHECKBOX Pain prevents me from sleeping at all.Section 10 - Balance  FORMCHECKBOX I can stand as long as I want without upper extremity support.  FORMCHECKBOX I can stand as long as I want without upper extremity support; but require a wide stance.  FORMCHECKBOX I can stand as long as I want without upper extremity support; but need to rest after 10 minutes.  FORMCHECKBOX I can stand steady with upper extremity support for as long as I want.  FORMCHECKBOX I can stand steady with upper extremity support for 10 minutes or less.  FORMCHECKBOX I cannot stand at all without assistance because I am unsteady.Section 5 Gait  FORMCHECKBOX I can walk as far as I want without a limp.  FORMCHECKBOX I can walk short distances without a limp.  FORMCHECKBOX I walk with a mild limp.  FORMCHECKBOX I walk with a moderate limp.  FORMCHECKBOX I walk with a severe limp.  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