Center of Movement — PM&R & Osteopathic Medicine

This questionnaire measures how your low back pain affects your ability to manage everyday activities. Please select the one statement in each section that best describes you today.

Patient Name

Date

Section 1 — Pain Intensity

I have no pain at the momentThe pain is very mild at the momentThe pain is moderate at the momentThe pain is fairly severe at the momentThe pain is very severe at the momentThe pain is the worst imaginable at the moment

Section 2 — Personal Care

I can look after myself normally without causing extra painI can look after myself normally but it causes extra painIt is painful to look after myself and I am slow and carefulI need some help but can manage most of my personal careI need help every day in most aspects of self-careI do not get dressed, wash with difficulty, and stay in bed

Section 3 — Lifting

I can lift heavy weights without extra painI can lift heavy weights but it gives extra painPain prevents me from lifting heavy weights off the floor but I can if they are conveniently placedPain prevents me from lifting heavy weights but I can manage light to medium weightsI can only lift very light weightsI cannot lift or carry anything

Section 4 — Walking

Pain does not prevent me from walking any distancePain prevents me from walking more than 1 milePain prevents me from walking more than 1/2 milePain prevents me from walking more than 100 yardsI can only walk using a stick or crutchesI am in bed most of the time

Section 5 — Sitting

I can sit in any chair as long as I likeI can only sit in my favorite chair as long as I likePain prevents me from sitting more than 1 hourPain prevents me from sitting more than 30 minutesPain prevents me from sitting more than 10 minutesPain prevents me from sitting at all

Section 6 — Standing

I can stand as long as I want without extra painI can stand as long as I want but it gives me extra painPain prevents me from standing for more than 1 hourPain prevents me from standing for more than 30 minutesPain prevents me from standing for more than 10 minutesPain prevents me from standing at all

Section 7 — Sleeping

My sleep is never disturbed by painMy sleep is occasionally disturbed by painBecause of pain I have less than 6 hours sleepBecause of pain I have less than 4 hours sleepBecause of pain I have less than 2 hours sleepPain prevents me from sleeping at all

Section 8 — Social Life

My social life is normal and gives me no extra painMy social life is normal but increases the degree of painPain has no significant effect on my social life apart from limiting my more energetic interestsPain has restricted my social life and I do not go out as oftenPain has restricted my social life to my homeI have no social life because of pain

Section 9 — Traveling

I can travel anywhere without painI can travel anywhere but it gives me extra painPain is bad but I manage journeys over two hoursPain restricts me to journeys of less than one hourPain restricts me to short necessary journeys under 30 minutesPain prevents me from traveling except to receive treatment

Section 10 — Employment / Homemaking

My normal homemaking/job activities do not cause painMy normal activities cause extra pain but I can still perform all that is requiredI can perform most of my normal activities but pain prevents me from performing more physically stressful onesPain prevents me from doing anything but light dutiesPain prevents me from doing even light dutiesPain prevents me from performing any job or homemaking chore

Oswestry Disability Index