Wake Forest
Cary
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Wake Forest | 919.556.4678
Cary | 919.468.0955
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Kaela Bellefeuil, DPT, OCS
Olivier Chassin, DPT, Cert. DN
Tyler Clements, DPT
Jaime DelGenio, DPT, Cert. DN
Brian Gentile, PT, Cert. DN
Caitlin Goldsmith, DPT
Michael Holt McPherson, DPT
Grant Nelson, DPT, Cert. DN
Holly Schmitz, DPT
Heather Smith, DPT
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Modified OSWESTRY Low Back Pain Disability Questionnaire
Patient First Name
*
Patient Last Name
*
Date Of Birth
*
MM slash DD slash YYYY
This questionnaire has been designed to give your therapist information as to how your back pain has affected your ability to manage in every day life. Please answer every question. For each question, place a check mark by the statement that BEST describes your condition today. We realize you may feel that two of the statements may describe your condition, but please
mark only the line which most closely describes your current condition.
Pain Intensity
*
The pain is mild and comes and goes.
The pain is mild and does not vary much.
The pain is moderate and comes and goes.
The pain is moderate and does not vary much.
The pain is severe and comes and goes.
The pain is severe and does not vary much.
Personal Care (Washing, Dressing, etc.)
*
I do not have to change the way I wash and dress myself to avoid pain.
I do not normally change the way I wash or dress myself even though it causes some pain.
Washing and dressing increases my pain, but I can do it without changing my way of doing it.
Washing and dressing increases my pain, and I find it necessary to change the way I do it.
Because of my pain I am partially unable to wash and dress without help.
Because of my pain I am completely unable to wash or dress without help.
Lifting
*
I can lift heavy weights without increased pain.
I can lift heavy weights but it causes increased pain
Pain prevents me from lifting heavy weights off of the floor, but I can manage if they are conveniently positioned (ex. on a table, etc.).
Pain prevents me from lifting heavy weights off of the floor, but I can manage light to medium weights if they are conveniently positioned.
I can lift only very light weights.
I can not lift or carry anything at all.
Walking
*
I have no pain when walking.
I have pain when walking, but I can still walk my required normal distances.
Pain prevents me from walking long distances.
Pain prevents me from walking intermediate distances.
Pain prevents me from walking even short distances.
Pain prevents me from walking at all.
Sitting
*
Sitting does not cause me any pain.
I can only sit as long as I like providing that I have my choice of seating surfaces.
Pain prevents me from sitting for more than 1 hour.
Pain prevents me from sitting for more than 1/2 hour.
Pain prevents me from sitting for more than 10 minutes.
Pain prevents me from sitting at all.
Standing
*
I can stand as long as I want but my pain increases with time.
Pain prevents me from standing more than 1 hour.
Pain prevents me from standing more than 1 hour.
Pain prevents me from standing more than 10 minutes.
I avoid standing because it increases my pain right away.
Sleeping
*
I get no pain when I am in bed.
I get pain in bed, but it does not prevent me from sleeping well.
Because of my pain, my sleep is only 3/4 of my normal amount.
Because of my pain, my sleep is only 1/2 of my normal amount.
Because of my pain, my sleep is only 1/4 of my normal amount.
Pain prevents me from sleeping at all.
Social Life
*
My social life is normal and does not increase my pain.
My social life is normal, but it increases my level of pain.
Pain prevents me from participating in more energetic activities (ex. sports, dancing, etc.)
Pain prevents me from going out very often.
Pain has restricted my social life to my home.
I have hardly any social life because of my pain.
Employment/Homemaking
*
My normal job/homemaking activities do not cause pain.
My normal job/homemaking activities increase my pain, but I can still perform all that is required of me.
My normal job/homemaking activities increase my pain, but I can still perform all that is required of me.
Pain prevents me from doing anything but light duties.
Pain prevents me from doing even light duties.
Pain prevents me from performing any job or homemaking chores.
Traveling
*
I get no increased pain when traveling.
I get some pain while traveling, but none of my usual forms of travel make it any worse.
I get some pain while traveling, but none of my usual forms of travel make it any worse.
I get increased pain while traveling which causes me to seek alternative forms of travel.
My pain restricts all forms of travel except that which is done while I am lying down.
My pain restricts all forms of travel except that which is done while I am lying down.
Today's Date: 03/29/2023
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