Oswestry Low Back Pain 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 select the one that indicates the statement which MOST clearly describes your problem.

"*" indicates required fields

First Name*

Last Name*

Section 1 – Pain intensity*

Section 2 – Personal care (washing, dressing etc)*

Section 3 – Lifting*

Section 4 – Walking*

Section 5 – Sitting*

Section 6 – Standing*

Section 7 – Sleeping*

Section 8 – Sex life (if applicable)*

Section 9 – Social Life*

Section 10 – Traveling*