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info@yourpickeringchiropractors.ca
905-831-3939
info@yourpickeringchiropractors.ca
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New Patient Paperwork Form
Home
Our Team
Services
Chiropractic Care
Acupuncture
Massage Therapy
Custom Orthotics
MED-X Laser
Ultrasound Therapy
TENS
Therapeutic Exercise & Rehabilitation Guidance
Common Conditions
Back Pain
Neck Pain
Headaches and Migraines
Sports And Repetitive Strain Injuries
Job Related Pain / Ergonomics
Arthritis / Joint Pain / Stiffness
Foot / Heel Pain
Pre / Post Pregnancy Related Pain
Concussion Management
Motor vehicle accident related
Blog
Contact
New Patient Paperwork Form
Home
Our Team
Services
Chiropractic Care
Acupuncture
Massage Therapy
Custom Orthotics
MED-X Laser
Ultrasound Therapy
TENS
Therapeutic Exercise & Rehabilitation Guidance
Common Conditions
Back Pain
Neck Pain
Headaches and Migraines
Sports And Repetitive Strain Injuries
Job Related Pain / Ergonomics
Arthritis / Joint Pain / Stiffness
Foot / Heel Pain
Pre / Post Pregnancy Related Pain
Concussion Management
Motor vehicle accident related
Blog
Contact
New Patient Paperwork Form
Home
Our Team
Services
Chiropractic Care
Acupuncture
Massage Therapy
Custom Orthotics
MED-X Laser
Ultrasound Therapy
TENS
Therapeutic Exercise & Rehabilitation Guidance
Common Conditions
Back Pain
Neck Pain
Headaches and Migraines
Sports And Repetitive Strain Injuries
Job Related Pain / Ergonomics
Arthritis / Joint Pain / Stiffness
Foot / Heel Pain
Pre / Post Pregnancy Related Pain
Concussion Management
Motor vehicle accident related
Blog
Contact
New Patient Paperwork Form
LOW BACK PAIN AND DISABILITY QUESTIONNAIRE (Revised Oswestry)
PLEASE READ INSTRUCTIONS
This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but just mark the box which most closely describes your problem.
SECTION 1 - PAIN INTENSITY
(Required)
The pain comes and goes and is very mild.
The pain is mild and does not vary much.
The pain comes and goes and is moderate.
The pain comes and goes and is severe.
The pain is severe and does not vary much.
SECTION 6 - STANDING
(Required)
I can stand as long as I want without pain.
I have some pain on standing but it does not increase with time.
I cannot stand for longer than one hour without increasing pain.
I cannot stand for longer than·½ hour without increasing pain.
I cannot stand for longer than 10 minutes without increasing pain.
I avoid standing because it increases the pain straight away.
SECTION 2 - PERSONAL CARE
(Required)
I would not have to change my way of washing or dressing in order to avoid pain.
I do not normally change my way of washing or dressing even though it causes pain.
Washing and dressing increase the pain but I manage not to change my way of doing it.
Because of the pain I am unable to do some washing and dressing without help.
Because of the pain I am unable to do any washing and dressing without help.
SECTION 7 - SLEEPING
(Required)
I get no pain in bed.
I get pain in bed but it does not prevent me from sleeping well.
Because of pain my normal night's sleep is reduced by less than 1/4 .
Because of pain my normal night's sleep is reduced by less than ½.
Because of pain my normal night's sleep is reduced by less than ¾.
Pain prevents me from sleeping at all.
SECTION 3 - LIFTING
(Required)
I can lift heavy weights without extra pain.
I can lift heavy weights but it causes extra pain.
Pain prevents me from lifting heavy weights off the floor.
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g. on a table).
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.
I can only lift very light weights at the most.
SECTION 8 - SOCIAL LIFE
(Required)
My social life is normal and gives me no pain.
My social life is normal but increases the degree of pain.
Pain has no significant effect on my social life apart from limiting my more energetic interests (e.g. dancing, etc.)
Pain has restricted my social life and I do not go out very often.
Pain has restricted my social life to my home.
I have hardly any social life because of the pain.
SECTION 4 - WALKING
(Required)
I have not pain on walking.
I have some pain on walking but it does not increase wi1h distance.
I cannot walk, more than one km. without increasing pain.
I cannot walk more than ½ km. without increasing pain.
I cannot walk more than ¼ km. without increasing pain.
I cannot walk at all without increasing pain.
SECTION 9 - TRAVELLING
(Required)
I get not pain whilst travelling.
I get some pain whilst travelling but none of my usual forms of travel make it any worse.
I get extra pain whilst travelling but it does not compel me to seek alternative forms of travel.
I get extra pain whilst travelling which compels me to seek alternative forms of travel.
Pain restricts all forms of travel.
Pain prevents all forms of travel except that done lying down.
SECTION 5 - SITTING
(Required)
I can sit in any chair as long as I like.
I can only sit in my favourite chair as long as I like.
Pain prevents me from sitting more than one hour.
Pain prevents me from sitting more than half hour.
Pain prevents me from sitting more than 10 minutes.
I avoid sitting because it increases pain straight away.
SECTION 10 - CHANGING DEGREE OF PAIN
(Required)
My pain is rapidly getting better.
My pain fluctuates but overall is definitely getting better.
My pain seems to be getting better but improvement is slow at present.
My pain is neither getting better nor worse.
My pain is gradually worsening.
My pain is rapidly worsening.
Pain Scale
(Required)
Rate the severity of your pain on the following scale. 0=No Pain, 10=Excruciating Pain
