Oswesty Disability Index (ODI)

PATIENT NAME
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
MODIFIED OSWESTRY DISABILITY SCALE

Aka: Back pain questionnaire
Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability. Please circle the answers below that best apply.
Please rate your pain level with activity

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Very Severe Pain
1. Pain Intensity:
2. Personal care (Washing, dressing, etc.):
3. Lifting:
4. Walking:
5. Sitting:
6. Standing:
7. Sleeping:
8. Social Life:
9. Traveling:
10. Employment / Homemaking:
Treating Physical Therapist:
Should be Empty:

MODIFIED OSWESTRY DISABILITY SCALE