Modified Oswestry

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Please circle the answers below that BEST apply

* Indicates required field

Patient ID# *

Please rate your pain level with activity: (0= no pain; 10 = very severe pain *

0 1 2 3 4 5 6 7 8 9 10

How satisfied are you with the level of care and service provided? *

Very Satisfied Satisfied Unsatisfied Very Unsatisfied

Please rate your progress with functional activities from start of therapy to the point in time. *

Excellent Good Fair Poor

At this point in your treatment, have your therapy goals been met? *

Completely Met Mostly Met Partially Met Not Met

1. PAIN INTENSITY *

0 - I can tolerate the pain I have without having to use pain medication 1 - The pain is bad, but I can manage without having to take pain medication 2 - Pain medication provides me with complete relief from pain 3 - Pain medication provides me with moderate relief from pain 4 - Pain medication provides me with little relief from pain 5 - Pain medication has no effect on my pain

PERSONAL CARE (washing, dressing, etc) *

0 - I can take care of myself normally without causing increased pain 1 - I can take care of myself normally, but it increases my pain 2 - It is painful to take care of myself, and I am slow and careful 3 - I need help, but I am able to manage most of my personal care 4 - I need help every day in most aspects of my care 5 - I do not get dressed, wash with difficulty, and stay in bed

LIFTING *

0 - I can lift heavy weights without increased pain 1 - I can lift heavy weights, but it causes increased pain 2 - Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (eg. on a table) 3 - Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned 4 - I can lift only very light weights 5 - I cannot lift or carry anything at all

WALKING *

0 - Pain does not prevent me from walking any distance 1 - Pain prevents me from walking more than 1 mile 2 - Pain prevents me from walking more than 1/2 mile 3 - Pain prevents me from walking more than 1/4 mile 4 - I can only walk with crutches or a cane 5 - I am in bed most of the time and have to crawl to the toilet

SITTING *

0 - I can sit in any chair as long as I like 1 - I can only sit in my favorite chair as long as I like 2 - Pain prevents me from sitting more than 1 hour 3 - Pain prevents me from sitting more than 1/2 hour 4 - Pain prevents me from sitting more than 10 minutes 5 - Pain prevents me from sitting at all

STANDING *

0 - I can stand as long as I want without increased pain 1 - I can stand as long as I want but it increases my pain 2 - Pain prevents me from standing more than 1 hour 3 - Pain prevents me from standing more than 1/2 hour 4 - Pain prevents me from standing more than 10 minutes 5 - Pain prevents me from standing at all

SLEEPING *

0 - Pain does not prevent me from sleeping gwell 1 - I can sleep well only by using pain medication 2 - Even when I take pain medication, I sleep less than 6 hours 3 - Even when I take pain medication, I sleep less than 4 hours 4 - Even when I take pain medication, I sleep less than 2 hours 5 - Pain prevents me from sleeping at all

SOCIAL LIFE *

0 - My social life is normal and does not increase my pain 1 - My social life is normal, but it increases my level of pain 2 - Pain prevents me from participating in more energetic activities (eg, sports, dancing) 3 - Pain prevents me from going out very often 4 - Pain has restricted my social life to my home 5 - I have hardly any social life because of my pain

TRAVELING *

0 - I can travel anywhere without increased pain 1 - I can travel anywhere, but it increases my pain 2 - My pain restricts my travel over 2 hours 3 - My pain restricts my travel over 1 hour 4 - My pain restricts my travel to short necessary journeys under 1/2 hour 5 - My pain prevents all travel except for visits to the physician/therapist or hospital

EMPLOYMENT/HOMEMAKING *

0 - My normal homemaking/job activities do not cause pain 1 - My normal homemaking/job activities increase pain, but I can still perform all that is required of me 2 - I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (eg, lifting, vacuuming) 3 - Pain prevents me from doing anything but light duties 4 - Pain prevents me from doing even light duties 5 - Pain prevents me from performing any job or homemaking chores

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Home
Physical Therapy
- INFO >
  - Location
  - News
  - Blog
- Intake forms
- What to expect
- Staff >
- Services
Group Fitness
- Class Schedule
Sports Performance Program