REVISED OSWESTRY DISABILITY Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Social Life Personal Name *Date of Birth *Email Address *Phone Number *This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box that applies to you. We realize that you may consider that two of the statements in any one section relate to you, but please just mark the box that most closely describes your problem.Pain Intensity *The pain comes and goes and is very mild.The pain is mild and does not vary much.The pain comes and goes and is moderate.The pain is moderate and does not vary much.The pain comes and goes and is very severe.The pain is severe and does not vary much.Personal Care *I would not have to change my way of washing or dressing in order to avoid pain.I do not normally change my way of washing or dressing even though it causes some pain.Washing and dressing increases the pain, but I manage not to change my way of doing it.Washing and dressing increases the pain and I find it necessary to change my way of doing it.Because of the pain, I am unable to do some washing and dressing without help.Because of the pain, I am unable to do any washing and dressing without help.Lifting *I can lift heavy weights without extra pain.I can lift heavy weights, but it causes extra pain.Pain prevents me from lifting heavy weights off the floor, but I manage if they are conveniently positioned (e.g., on a table).Pain prevents me from lifting heavy weights off the floor.Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.I can only lift very light weights at the most.Walking *I have no pain on walking.I have some pain on walking, but it does not increase with distance.I cannot walk more than one mile without increasing pain.I cannot walk more than 1/2 mile without increasing pain.I cannot walk more than 1/4 mile without increasing pain.I cannot walk at all without increasing pain.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 1/2 hour.Pain prevents me from sitting more 10 minutes.I avoid sitting because it increases pain right away.Standing *I can stand as long as I want without pain.I have some pain on standing, but it does not increase with time.I cannot stand for longer than one hour without increasing pain.I cannot stand for longer than 1/2 hour without increasing pain.I cannot stand for longer than 10 minutes without increasing pain.I avoid standing because it increases the pain right away.Sleeping *I get no pain in bed.I get pain in bed, but it does not prevent me from sleeping well.Because of pain, my normal night’s sleep is reduced by less than 1/4.Because of pain, my normal night’s sleep is reduced by less than 1/2.Because of pain, my normal night’s sleep is reduced by less than 3/4.Pain prevents me from sleeping at all.Social Life *My social life is normal and gives me no pain.My social life is normal, but increases the degree of pain.Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc.Pain has restricted my social life and I do not go out very often.Pain has restricted my social life to my home.I have hardly any social life because of the pain.Travelling *I get no pain while travelling.I get some pain while travelling, but none of my usual forms of travel makes it any worse.I get extra pain while travelling, but it does not compel me to seek alternative forms of travel.I get extra pain while travelling, which compels me to seek alternative forms of travel.Pain restricts all forms of travel.Pain prevents all forms of travel except that done lying down.Changing Degree of Pain *My pain is rapidly getting better.My pain fluctuates, but is definitively getting better.My pain seems to be getting better, but improvement is slow at present.My pain is neither getting better nor worse.My pain is gradually worsening.My pain is rapidly worsening.Submit PAIN IS NOT A LIFESTYLE Get your quality of life back today. BOOK APPOINTMENT
