EPSTEIN
page 3 / 1159 . OCR, unverified
reason that the patient was unable to complete the form.
Form Completed by
Date
EFTA00313806
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Weil Camel Medicine
Center for Comprehel
Spine Care
Oswestry Disability Questionnaire
This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please
answer by checking one box in each section for the statement which best applies to you. We realize you may consider that two or more statements in
any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem.
Section 1: Pain Intensity
o I have no pain at the moment
o The pain is very mild at the moment
o The pain is moderate at the moment
o The pain is fairly severe at the moment
o The pain is very severe at the moment
o The pain is the worst imaginable at the moment
Section 2: Personal Care (eg. washing,
dressing)
I can look after myself normally without causing extra pain
o I can lock after myself normally but it causes extra pain
o It is painful to look after myself and I am slow and careful
o I need some help but can manage most of my personal care
o I need help every day in most aspects of self-care
o I do not get dressed, wash with difficulty and stay in bed
Section 3: Lifting
o I can lift heavy weights without extra pain
c I can lift heavy weights but it gives me extra pain
o Pain prevents me lifting heavy weights off the floor but I can
manage if they are conveniently placed (eg. on a table)
o Pain prevents me lifting heavy weights but I can manage
light to medium weights if they are conveniently positioned
o I can only lift very light weights
I cannot lift or carry anything
Section 4: Walking*
o Pain does not prevent me walking any distance
o Pain prevents me from walking more than 1 mile
o Pain prevents me from walking more than 'A mile
o Pain prevents me from walking more than 100 yards
o I can only walk using a cane or crutches
o I am in bed most of the time
Section 5: Sitting
o I can sit in any chair as long as I like
o I can only sit in my favorite chair as long as I like
o pain prevents me sitting more than one hour
o Pain prevents me from sitting more than 30 minutes
o Pain prevents me from sitting more than 10 minutes
o Pain prevents me from sitting at all
Section 6: Standing
o I can stand as long as I want without extra pain
o I can stand as long as I want but it gives me extra pain
o Pain prevents me from standing for more than 1 hour
o pain prevents me from standing for more than 30 minutes
o Pain prevents me from standing for more than 10 minutes
o Pain prevents me from standing at all
Section 7: Sleeping
o My sleep is never disturbed by pain
o My sleep is occasionally disturbed by pain
o Because of pain I have less than 6 hours sleep
o Because of pain I have less than 4 hours sleep
o Because of pain I have less than 2 hours sleep
o Pain prevents me from sleeping at all
Section 8: Sex Life (if applicable)
o My sex life is normal and causes no extra pain
My sex life is normal but causes some extra pain
o My sex life is nearly normal but is very painful
O My sex life is severely restricted by pain
o My sex life is nearly absent because of pain
c pain prevents any sex life at all
Section 9: Social Life
o My social life is normal and gives me no extra pain
o My social life is normal but increases the degree of pain
o Pain has no significant effect on my social life apart from
limiting my more energetic interests e.g. sport
o Pain has restricted my social life and I do not go out as often
o Pain has restricted my social life to my home
o I have no social life because of pain
Section 10: Travelling
o I can travel anywhere without pain
o I can travel anywhere but it gives me extra pain
o Pain is bad but I manage journeys over two hours
o Pain restricts me to journeys of less than one hour
o Pain restricts me to short necessary journeys under 30
minutes
o Pain prevents me from travelling except to receive treatment
EFTA00313807
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Weil Cornell Medicine
Center for Cn
Spine Cart-
Neck Disability Index
This questionnaire has been designed to give us information as to how your neck pain has affected your ability to manage in everyday life. Please
answer every section and mark in each section only the one box that applies to you. We realize you may consider that two or more statements in any
one section relate to you. but please just mark the box that most CJosety describes your problem.
Section 1: Pain Intensity
o I have no pain at the moment
o The pain is very mild at the moment
o The pain is moderate at the moment
o The pain is fairly severe at the moment
o The pain is very severe at the moment
o The pain is the worst imaginable at the moment
Section 2: Personal Care (Washing, Dressing,
etc.)
o I can look after myself normally without causing extra pain
o I can look after myself normally but it causes extra pain