ࡱ> \^[q` LbjbjqPqP 7P::VVVVVVVjv<j) x@ $ h}"9V```VVttt` VVt`ttVVt к"niFj t0)t#t#t#Vtt0$"tFbj )````jjjd $jjjjjjVVVVVV Office Use: Therapist:______ The Oswestry Upper 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 arm(s).  FORMCHECKBOX I have 75% of range of motion in my arm(s).  FORMCHECKBOX I have 50% of range of motion in my arm(s).  FORMCHECKBOX I have 25% of range of motion in my arm(s).  FORMCHECKBOX I can move my arm(s) with assistance.  FORMCHECKBOX I cannot move my arm(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  The 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 arm(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 arm strength is greatly restricted.  FORMCHECKBOX I have no strength in my arm(s).Section 3 Lifting  FORMCHECKBOX I can lift heavy items without extra pain.  FORMCHECKBOX I can lift heavy items but it gives extra pain.  FORMCHECKBOX I can lift heavy items if conveniently positioned.  FORMCHECKBOX I can lift light/medium items if conveniently positioned.  FORMCHECKBOX I can lift only very light weight items.  FORMCHECKBOX  I cannot lift anything 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 Recreation Activities  FORMCHECKBOX My recreational activities are normal and cause no extra pain.  FORMCHECKBOX My recreational activities are normal but cause extra pain.  FORMCHECKBOX Pain limits me from my more challenging recreational activities.  FORMCHECKBOX Pain has restricted my recreational activities moderately.  FORMCHECKBOX Pain has restricted my recreational activities severely.  FORMCHECKBOX I do no participate in any recreational activities because of pain.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 5 Work  FORMCHECKBOX I can do as much work as I want to.  FORMCHECKBOX I can only do my usual work but no more.  FORMCHECKBOX I can do most of my usual work but no more.  FORMCHECKBOX I cannot do my usual work.  FORMCHECKBOX I can hardly do any work at all.  FORMCHECKBOX I cannot do any work at all.Section 10 - Posture  FORMCHECKBOX I usually sit upright throughout the day without difficulty.  FORMCHECKBOX I have mild difficulty sitting upright throughout the day without difficulty.  FORMCHECKBOX I have a moderate degree of difficulty sitting upright.  FORMCHECKBOX I have a fairly difficult time maintaining upright posture.  FORMCHECKBOX I have severe difficulty maintaining upright posture.  FORMCHECKBOX I cannot sit upright at all.Section 11 - Rate your overall pain:  FORMTEXT       0 1 2 3 4 5 6 7 <>Xx$ B D ` b v x z = B C uiu]u]uhYh5CJaJhYh>*CJaJhYhCJaJ#jth_+h_+CJUaJ"jh_+CJUaJmHnHu#jh_+h_+CJUaJh_+CJaJjh_+CJUaJhoCJaJho5CJaJhq+5CJaJhoho5CJaJhZOCJaJhYCJaJ>D C ^ * _ 1 n  $If $Ifgd$a$gdo$a$gdYLC ^ _ m n o    ( ) * + 9 : ; ] ^ _ ` n o p ޲ޠގ|j#j,hhCJUaJ#jhhCJUaJ#jDhhCJUaJ#jhhCJUaJ#j\hhCJUaJhACJaJ#jhhCJUaJhCJaJjhCJUaJhYh5>*CJaJ)     / 0 1 2 @ A B l m n o } ɽyq_WhJ|CJaJ#jhYh_j CJUaJhR|CJaJ#jhYh_j CJUaJh>oCJaJhmCJaJh"eCJaJ#jhYh_j CJUaJhYCJaJjhYCJUaJhYh5>*CJaJhm5>*CJaJhYhJ|5>*CJaJhCJaJhACJaJ} ~      G H V W X ɕ{i{{W{#j7hh_j CJUaJ#jhh_j CJUaJjhCJUaJhYh5>*CJaJhCJaJ#jhYh_j CJUaJ#jxhYh_j CJUaJhYCJaJhJ|CJaJhACJaJhmCJaJjhYCJUaJ#jhYh_j CJUaJ"  G /"7m0{{{{{{uuuuuu$If $Ifgdzkdd$$Ifl0z\: t0:644 la ./0>?@A !".678vhYjhYhYCJUaJhoh5>*CJaJhm5>*CJaJh>o5>*CJaJ#j hh_j CJUaJhoCJaJ#jhh_j CJUaJ#jhh_j CJUaJhACJaJ#jhh_j CJUaJhCJaJjhCJUaJhJ|CJaJ!8FGHJklmn|}~./01?@Afghiwļļļsļaļ#jY hYh_j CJUaJ#j hYh_j CJUaJh ICJaJ#jm hYh_j CJUaJ#j hYh_j CJUaJhYhJ|CJaJhACJaJhmCJaJh6CJaJjhYhYCJUaJ#j hYh_j CJUaJhYhYCJaJ%0h+o%9o~zkdE $$Ifl0z\: t0:644 la$Ifwxy)*+,:ûqiaiOiai#j hYh_j CJUaJhR|CJaJhJ|CJaJ#j hYh_j CJUaJhYCJaJjhYCJUaJhq+5>*CJaJhR|5>*CJaJhYhJ|5>*CJaJhCJaJhYhJ|CJaJhACJaJhmCJaJjhYhYCJUaJ#j hYh_j CJUaJ:;<mnop~#$%18ٕ{mbhm5>*CJaJhYhJ|5>*CJaJh>oCJaJ#jhYh_j CJUaJhq+CJaJ#j|hYh_j CJUaJ#jhYh_j CJUaJhYCJaJhJ|CJaJhACJaJhR|CJaJjhYCJUaJ#j hYh_j CJUaJ"89:HIJmnop~FGHIWXYļޟėޅļsļaļ#j@hYh_j CJUaJ#jhYh_j CJUaJ#jThYh_j CJUaJh6CJaJ#jhYh_j CJUaJhYhJ|CJaJhACJaJhmCJaJ#jhhYh_j CJUaJhYCJaJjhYCJUaJhYh5>*CJaJ&HA,v~uuuuuuu $IfgdXXzkd,$$Ifl0z\: t0:644 la$If ?@ABPQRʿmeSe#jh_j hXXCJUaJhq+CJaJ#jh_j hXXCJUaJhXXCJaJjhXXCJUaJh_j hXX5>*CJaJhq+5>*CJaJhXX5>*CJaJhCJaJhYhJ|CJaJhACJaJhmCJaJjhYCJUaJ#jhYh_j CJUaJhYCJaJ*+,-;<=tuvwٷ٥ٓɋ}r}dXjhYCJUaJh_j hJ|5>*CJaJh_j 5>*CJaJh_j hY5>*CJaJhJ|CJaJ#jh_j hXXCJUaJ#jch_j hXXCJUaJ#jh_j hXXCJUaJhACJaJhmCJaJhXXCJaJjhXXCJUaJ#jwh_j hXXCJUaJ!-./\]^_mno,-./=>?defp#jhYh_j CJUaJ#j'hYh_j CJUaJ#jhYh_j CJUaJ#j;hYh_j CJUaJ#jhYh_j CJUaJhACJaJh>oCJaJjhYCJUaJ#jOhYh_j CJUaJhYCJaJ)^.fgw#O~uuuuuuu $IfgdXXzkd$$Ifl0z\: t0:644 la$If fgoprvwx!"#$234MNOP^zȦhȦ#jhYhXXCJUaJ#j^hYhXXCJUaJ#jhYhXXCJUaJhACJaJhmCJaJ#jrhYhXXCJUaJhXXCJaJjhXXCJUaJhm5>*CJaJhXX5>*CJaJhYhXX5>*CJaJhJ|CJaJ&^_`!ɷѯ}qiWqOqihYCJaJ#j6h_j h_j CJUaJh_j CJaJjh_j CJUaJh_j h5>*CJaJhm5>*CJaJh_j 5>*CJaJh_j hY5>*CJaJhJ|CJaJ#jhYhXXCJUaJhXXCJaJhACJaJhmCJaJjhXXCJUaJ#jJhYhXXCJUaJqLL~ui $$Ifa$gdLp $IfgdLpzkd$$Ifl0z\: t0:644 la$If !"#%opqr  ,.0ṧṕṃ{iahCJaJ#jh_j h_j CJUaJh/{CJaJ#jh_j h_j CJUaJ#jh_j h_j CJUaJ#j"h_j h_j CJUaJh_j CJaJhYCJaJhACJaJhmCJaJh6CJaJjh_j CJUaJ#jh_j h_j CJUaJ"BFH\^`jltLL0L6LLLLL˹ӧߜߜhUhYhLpCJaJ"jh_+CJUaJmHnHu#jYh_+h_+CJUaJh_+CJaJjh_+CJUaJhLpCJaJhLp5>*CJaJhYhLp5>*CJaJ 8 9 10 No pain mild discomfort distressing horrible excruciating LLLgdogkd$$Ifl\:: t0:644 la5&P0:p_+= /!"#$% tDText1tDText2tDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5tDeCheck6vDeCheck13vDeCheck14vDeCheck15vDeCheck16vDeCheck17vDeCheck18]$$If!vh55#v#v:Vl t:655tDeCheck7tDeCheck8tDeCheck9vDeCheck10vDeCheck11vDeCheck12vDeCheck19vDeCheck20vDeCheck21vDeCheck22vDeCheck23vDeCheck24]$$If!vh55#v#v:Vl t:655vDeCheck25vDeCheck26vDeCheck27vDeCheck28vDeCheck29vDeCheck30vDeCheck31vDeCheck32vDeCheck33vDeCheck34vDeCheck35vDeCheck36]$$If!vh55#v#v:Vl t:655vDeCheck51vDeCheck52vDeCheck53vDeCheck54vDeCheck55vDeCheck56vDeCheck37vDeCheck38vDeCheck39vDeCheck41vDeCheck40vDeCheck42]$$If!vh55#v#v:Vl t:655vDeCheck13vDeCheck14vDeCheck15vDeCheck16vDeCheck17vDeCheck18vDeCheck43vDeCheck57vDeCheck58vDeCheck59vDeCheck60vDeCheck61]$$If!vh55#v#v:Vl t:655tDText3G$$If!vh5:#v::Vl t:65:8@8 Normal_HmH sH tH DAD Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List j@j  Table Grid7:V0HH Y Balloon TextCJOJQJ^JaJPC^*_1nG/"7m0h+o% 9 o H A , v  ^ .fgw#OqN|}00000000000 0000000 0 0000000 0000000 0 0000000 0000000 0 0000000 0000000 0 0000000 0000000 0 00 0 0|}K03K03 {0T y00 {00 y00K0C } 8w:8f^!L !#$ 0LL"'L^n*:_o1An~GW/?7Gm}0@hx+;o 9 I o   H X  A Q , < v  . ^ n .>w#3O_"qN^FFG$G$G$G$G$G$G G G G G G G G G G G G G$G$G$G$G$G$G G G G G G G G G G G G G$G$G$G$G$G$G G G G G G G$G$G$G$G$G$G G G G G G F9Text1Text2Check1Check2Check3Check4Check5Check6Check13Check14Check15Check16Check17Check18Check7Check8Check9Check10Check11Check12Check19Check20Check21Check22Check23Check24Check25Check26Check27Check28Check29Check30Check31Check32Check33Check34Check35Check36Check51Check52Check53Check54Check55Check56Check37Check38Check39Check41Check40Check42Check43Check57Check58Check59Check60Check61Text3_+`2oH08n1i,p: p I B - 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