www.orthopaedicscores.com
Date of completion
Back Pain Index
Clinician's name (or ref)
Patient's name (or ref)
 
This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every  section by marking the one statement that applies to you.  If two or more statements in one section apply, please mark the one statement that most closely describes your problem.
During the past 4 weeks......  
Section 1 - Pain Intensity   Section 6 - Standing
The pain comes and goes and is very mild.   I can stand as long as I want without pain.
The pain is mild and does not vary much.   I have some pain while standing but it does not increase with time.
The pain comes and goes and is moderate.   I cannot stand for longer than 1 hour without increasing pain.
The pain is moderate and does not vary much.   I cannot stand for longer than ½ hour without increasing pain.
The pain comes and goes and is very severe.   I cannot stand for longer than 10 minutes without increasing pain.
The pain is very severe and does not vary much.   I avoid standing because it increases pain immediately.
     
Section 2 - Personal Care (e.g., Washing, Dressing)   Section 7 - Sleeping
I do not have to change my way of washing or dressing in order to avoid pain.   I get no pain in bed.

I do not normally change my way of washing or dressing even though it causes some pain.

   I get pain in bed but it does not prevent met from sleeping well.
Washing and dressing increases the pain but I manage not to change my way of doing it.   Because of pain my normal sleep is reduced by less than 25%.

Washing and dressing increase the pain and I find it necessary to change my way of doing it.

   Because of pain my normal sleep is reduced by less than 50%.
Because of the pain I an unable to do some washing and dressing without help.   Because of pain my normal sleep is reduced by less than 75%.
Because of the pain I am unable to do any washing and dressing without help.   Pain prevents me from sleeping at all.
     
Section 3 - Lifting   Section 8 - Changing degree of pain
I can lift heavy weights without extra pain.   My pain is rapidly getting better.
I can lift heavy weights but it causes extra pain.   My pain fluctuates but overall is definitely getting better.
Pain prevents me from lifting heavy weights off the floor.   My pain seems to be getting better but improvement is slow.
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (eg on a table).   My pain is neither getting better or worse.
Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned.   My pain is gradually worsening.
I can lift only very light weights.   My pain is rapidly worsening.
     
Section 4 - Walking   Section 9 - Social Life
I have no pain while walking.   My social life is normal and gives me no extra pain.
I have some pain while walking but it doesn’t increase with distance.   My social life is normal but increases the degree of pain.
I cannot walk more than 1 mile without increasing pain.   Pain has no significant effect on my social life apart from limiting my more energetic interests (eg dancing, etc).
I cannot walk more than ½ mile without increasing pain.   Pain has restricted my social life and I do not go out very often.
I cannot walk more than ¼ mile without increasing pain.   Pain has restricted my social life to my home.
I cannot walk at all without increasing pain.   I have hardly any social life because of the pain.
     
Section 5 - Sitting   Section 10 - Traveling
I can sit in any chair as long as I like.   I get no pain while traveling.
I can sit in my favourite chair for as long as I like.   I get some pain while traveling but none of my usual forms of travel make it worse.
Pain prevents me from sitting for more than 1 hour.   I get extra pain while traveling but it does not cause me to seek alternate forms of travel.
Pain prevents me from sitting for more than ½ an hour.   I get extra pain while traveling which cause me to seek alternate forms of travel.
Pain prevents me from sitting for more that 10 minutes.   Pain restricts all forms of travel except that done while lying down.
I avoid sitting because it increases pain immediately.   Pain restricts all forms of travel.
     
Previous Treatment
Over the past three months have you received treatment, tablets or medicines of any kind for your back or leg pain? (Please tick the appropriate box. )

 
......if yes, please state the type of treatment you have received)

 
     
To save this data please print or
The Back Pain Index Score is: %

Reference for Score: Fairbank JC, Couper J, Davies JB, O'Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980 Aug;66(8):271-3. link
©2006 Kurer/Gooding/Dazines