Oswestry Questionnaire

Oswestry questionnaire is a series of questions which is designed to analyze patients with lower back pain. It is done with the aim of establishing how severe the lower back pain is, in an individual’s case and what can be its consequences.

Oswestry Questionnaire Sample

Name:               __________________________________________________________________

Date of birth:             __________________          Gender:     __________________

Address ____________________________________________________________________________________________________________________________________________________________

  1. Your Pain Intensity:
    1. No pain
    2. Very mild
    3. Moderate pain
    4. Quite severe at this moment
    5. Very severe
    6. Almost intolerable
  1. Personal care
    1. Normal chores, activities do not cause pain
    2. Feel pain taking care of myself, work slowly and carefully
    3. Can do most of my activities but require someone to help
    4. Need other’s help for most activities
    5. Observe difficulty in all activities, stay in bed.
  1. Lifting
    1. Lifting heavy weights does not cause me pain
    2. Can lift heavy weights but it causes me pain
    3. Avoid lifting from the floor but can handle if they are on table
    4. Just light weights
    5. Unable to lift or carry any weight
  1. Walking
    1. Can walk any distance without trouble
    2. Cannot walk after 1 mile because of pain
    3. Cannot walk after half a mile
    4. Cannot walk beyond quarter mile
    5. Can walk only with stick or crutches
    6. In bed most of the time and need to crawl to the toilet
  1. Sitting
    1. Can sit on a chair as long as I wish
    2. Can sit only in comfortable chairs
    3. Can’t sit more than 1 hour
    4. Not more than half an hour
    5. Not more than 10 minutes
    6. Can’t sit at all
  1. Standing
    1. Can stand for long without pain
    2. Can’t stand beyond 1 hour
    3. Not beyond 30 minutes
    4. Not beyond 10 minutes
    5. Pain prevents from standing at all
  1. Sleeping
    1. No problem in sleeping due to pain
    2. Sleep less than 6 hrs even with pills
    3. Less than 4 hrs with pills
    4. Less than 2 hrs with pills
    5. Can’t sleep due to pain
  1. Sex
    1. Normal sex life
    2. Normal but causes some pain
    3. Almost normal but very painful at times.
    4. Sex restricted because of pain
    5. No sex
  1. Social Life
    1. Normal with no extra pain
    2. Normal but with some pain
    3. Cannot dance or enjoy
    4. Do not go out because of pain
    5. Home tied
    6. No social life
  1. Travelling
    1. Can go anywhere
    2. Can go anywhere but causes me pain on long journeys
    3. Cannot travel beyond 1 hr
    4. Cannot travel beyond 30 minutes
    5. Cannot travel beyond 10 minutes
    6. I don’t travel because of pain (other than going to doctor/hospital)


Category: Health Questionnaire

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