OSWESTRY LOW BACK DISABILITY QUESTIONNAIRE

Instructions: this questionnaire has been designed to give us information as to how your back pain has affected
your ability to manage everyday life. Please answer every section and mark in each section only the ONE box
which applies to you at this time. We realize you may consider 2 of the statements in any section may relate to
you, but please mark the box which most closely describes your current condition.

1. PAIN INTENSITY 6. STANDING

… I can tolerate the pain I have without having to use … I can stand as long as I want without extra pain
pain killers … I can stand as long as I want but it gives me extra pain
… The pain is bad but I manage without taking pain … Pain prevents me from standing for more than one hour
killers … Pain prevents me from standing for more than 30 minutes
… Pain killers give complete relief from pain … Pain prevents me from standing for more than 10 minutes
… Pain killers give moderate relief from pain … Pain prevents me from standing at all
… Pain killers give very little relief from pain
… Pain killers have no effect on the pain and I do not use
them
2. PERSONAL CARE (e.g. Washing, Dressing) 7. SLEEPING
… I can look after myself normally without causing extra … Pain does not prevent me from sleeping well
pain … I can sleep well only by using medication
… I can look after myself normally but it causes extra … Even when I take medication, I have less than 6 hrs sleep
pain … Even when I take medication, I have less than 4 hrs sleep
… It is painful to look after myself and I am slow and … Even when I take medication, I have less than 2 hrs sleep
careful … Pain prevents me from sleeping at all
… I need some help but manage most of my personal care
… I need help every day in most aspects of self care
… I don’t get dressed, I was with difficulty and stay in
bed
3. LIFTING 8.
SOCIAL LIFE
… I can lift heavy weights without extra pain … My social life is normal and gives me no extra pain
… I can lift heavy weights but it gives extra pain … My social life is normal but increases the degree of pain
… Pain prevents me from lifting heavy weights off the … Pain has no significant effect on my social life apart from
floor, but I can manage if they are conveniently limiting my more energetic interests, i.e. dancing, etc.
positioned, i.e. on a table … Pain has restricted my social life and I do not go out as often
… Pain prevents me from lifting heavy weights, but I can … Pain has restricted my social life to my home
manage light to medium weights if they are … I have no social life because of pain
conveniently positioned
… I can lift very light weights
… I cannot lift or carry anything at all

4. WALKING 9. TRAVELLING
… Pain does not prevent me walking any distance … I can travel anywhere without extra pain
… Pain prevents me walking more than one mile … I can travel anywhere but it gives me extra pain
… Pain prevents me walking more than ½ mile … Pain is bad, but I manage journeys over 2 hours
… Pain prevents me walking more than ¼ mile … Pain restricts me to journeys of less than 1 hour
… I can only walk using a stick or crutches … Pain restricts me to short necessary journeys under 30
… I am in bed most of the time and have to crawl to the minutes
toilet … Pain prevents me from traveling except to the doctor or
hospital
5. SITTING 10. EMPLOYMENT/ HOMEMAKING
… I can sit in any chair as long as I like … My normal homemaking/ job activities do not cause pain.
… I can only sit in my favorite chair as long as I like … My normal homemaking/ job activities increase my pain, but
… Pain prevents me from sitting more than one hour I can still perform all that is required of me.
… Pain prevents me from sitting more than ½ hour … I can perform most of my homemaking/ job duties, but pain
… Pain prevents me from sitting more than 10 minutes prevents me from performing more physically stressful
… Pain prevents me from sitting at all activities (e.g. lifting, vacuuming)
… 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.
THE
QuickDASH
OUTCOME MEASURE

INSTRUCTIONS

This questionnaire asks about your

symptoms as well as your ability to
perform certain activities.

Please answer every question, based

on your condition in the last week,
by circling the appropriate number.

If you did not have the opportunity

to perform an activity in the past
week, please make your best estimate
of which response would be the most
accurate.

It doesn’t matter which hand or arm

you use to perform the activity; please
answer based on your ability regardless
of how you perform the task.

NAME _______________________________

DATE ___________________

MR No. __________________
 QuickDASH
Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.

NO MILD MODERATE SEVERE

UNABLE
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY

1. Open a tight or new jar. 1 2 3 4 5

2. Do heavy household chores (e.g., wash walls, floors). 1 2 3 4 5

3. Carry a shopping bag or briefcase. 1 2 3 4 5

4. Wash your back. 1 2 3 4 5

5. Use a knife to cut food. 1 2 3 4 5

6. Recreational activities in which you take some force

or impact through your arm, shoulder or hand 1 2 3 4 5
(e.g., golf, hammering, tennis, etc.).

QUITE
NOT AT ALL SLIGHTLY MODERATELY EXTREMELY
A BIT

7. During the past week, to what extent has your

arm, shoulder or hand problem interfered with 1 2 3 4 5
your normal social activities with family, friends,
neighbours or groups?

NOT LIMITED SLIGHTLY MODERATELY VERY

UNABLE
AT ALL LIMITED LIMITED LIMITED

8. During the past week, were you limited in your

work or other regular daily activities as a result 1 2 3 4 5
of your arm, shoulder or hand problem?

Please rate the severity of the following symptoms

in the last week. (circle number) NONE MILD MODERATE SEVERE EXTREME

9. Arm, shoulder or hand pain. 1 2 3 4 5

10. Tingling (pins and needles) in your arm, 1 2 3 4 5

shoulder or hand.

SO MUCH
NO MILD MODERATE SEVERE DIFFICULTY
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY THAT I
CAN’T SLEEP

11. During the past week, how much difficulty have

you had sleeping because of the pain in your arm, 1 2 3 4 5
shoulder or hand? (circle number)

( )
QuickDASH DISABILITY/SYMPTOM SCORE = (sum of n responses) - 1 x 25, where n is equal to the number
of completed responses. n
A QuickDASH score may not be calculated if there is greater than 1 missing item.
 QuickDASH

WORK MODULE (OPTIONAL)

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including
homemaking if that is your main work role).
Please indicate what your job/work is:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

❐ I do not work. (You may skip this section.)

Please circle the number that best describes your physical ability in the past week.

Did you have any difficulty: NO MILD MODERATE SEVERE

UNABLE
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY

1. using your usual technique for your work? 1 2 3 4 5

2. doing your usual work because of arm,

1 2 3 4 5
shoulder or hand pain?

3. doing your work as well as you would like? 1 2 3 4 5

4. spending your usual amount of time doing your work? 1 2 3 4 5

SPORTS/PERFORMING ARTS MODULE (OPTIONAL)

The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or
sport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which is
most important to you.
Please indicate the sport or instrument which is most important to you:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

❏ I do not play a sport or an instrument. (You may skip this section.)

Please circle the number that best describes your physical ability in the past week.

Did you have any difficulty: NO MILD MODERATE SEVERE

UNABLE
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY

1. using your usual technique for playing your

instrument or sport? 1 2 3 4 5

2. playing your musical instrument or sport because

1 2 3 4 5
of arm, shoulder or hand pain?

3. playing your musical instrument or sport

1 2 3 4 5
as well as you would like?

4. spending your usual amount of time

1 2 3 4 5
practising or playing your instrument or sport?

SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by
4 (number of items); subtract 1; multiply by 25.
An optional module score may not be calculated if there are any missing items. © INSTITUTE FOR WORK & HEALTH 2006. ALL RIGHTS RESERVED
 The Western Ontario and McMaster Universities Osteoarthritis Index
(WOMAC)

Name:____________________________________________ Date:________________
Instructions: Please rate the activities in each category according to the following
scale of difficulty: 0 = None, 1 = Slight, 2 = Moderate, 3 = Very, 4 = Extremely
Circle one number for each activity_________________________________________
Pain 1. Walking 0 1 2 3 4
2. Stair Climbing 0 1 2 3 4
3. Nocturnal 0 1 2 3 4
4. Rest 0 1 2 3 4
__________________5. Weight bearing 0 1 2 3 4
Stiffness 1. Morning stiffness 0 1 2 3_4
__________________2. Stiffness occurring later in the day 0 1 2 3 4
Physical Function 1. Descending stairs 0 1 2 3 4
2. Ascending stairs 0 1 2 3 4
3. Rising from sitting 0 1 2 3 4
4. Standing 0 1 2 3 4
5. Bending to floor 0 1 2 3 4
6. Walking on flat surface 0 1 2 3 4
7. Getting in / out of car 0 1 2 3 4
8. Going shopping 0 1 2 3 4
9. Putting on socks 0 1 2 3 4
10. Lying in bed 0 1 2 3 4
11. Taking off socks 0 1 2 3 4
12. Rising from bed 0 1 2 3 4
13. Getting in/out of bath 0 1 2 3 4
14. Sitting 0 1 2 3 4
15. Getting on/off toilet 0 1 2 3 4
16. Heavy domestic duties 0 1 2 3 4
17. Light domestic duties 0 1 2 3 4

Total Score: ______ / 96 = _______%

Comments / Interpretation (to be completed by therapist only):