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Modified Oswestry – Low Back Questionnaire
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Patient First Name:
*
Patient Last Name:
*
Date of Birth
DOB Month
*
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DOB Day
*
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DOB Year
*
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2015
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Gender
*
Male
Female
Diagnosis
Back
Neck
Patient Kareo ID #
*
Dx Matching Patient Chart
*
Today's Date of Service
Date of Service Month
*
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January
February
March
April
May
June
July
August
September
October
November
December
Date of Service Day
*
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Date of Service Year
*
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2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1996
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Visit # from First Date of Dx
*
The number of visits the patient has done up to that point with the starting date the same as the first date their Dx was on the patients chart
# of Days Since Last Service
*
All forms are to be filled prior to service. Example calculation for number of days: Friday was the patients last visit, Monday is when the patient fills this out again. The answer is 3 days.
Primary Treating Physical Therapist
*
Anderson, Michael
Burhop, Erica
Darley, Kathleen
Entwhistle, Alyson
Hagan, Chris
Jana, Lindsay
Johnson. Rebecca
Kim, Esther
LeBeau, Robert
Lesh, Freda
Lindquist Lengar, Sarah
Macza, Joanne
Mallari, Lauren
Matsakis, Antigone
McKechnie, Kate
McCann, Melissa
Murison, Bradley
Odaira, Toshi
Oury, April
Patel, Ankit
Petry, Garrett
Raciopi, Elizabeth
Schmitt, Leah
Simonetti, Meghan
Snyder, Aaron
Thompson, Kane
Wrozsek, Dan
Clinic Site
*
Downtown
Lincoln Park
Oak Brook
Oak Park
Wheaton
Winnetka
Low Back Questionnaire
Instructions: 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.
Please rate your pain level with activity
*
Pain Intensity
*
0 - The pain comes and goes and is very mild.
1 - The pain is mild and does not vary much.
2 - The pain comes and goes and is moderate.
3 - The pain is moderate and does not vary much.
4 - The pain comes and goes and is severe.
5 - The pain is severe and does not vary much.
Personal Care
*
0 - I would not have to change my way of dressing in order to avoid pain.
1 - I do not normally change my way of washing or dressing even though it causes some pain.
2 - Washing and dressing increases the pain, but I manage not to change my way of doing it.
3 - Washing and dressing increases the pain, and I find it necessary to change my way of doing it.
4 - Because of the pain, I am unable to do some washing and dressing without help.
5 - Because of the pain, I am unable to do any washing or dressing without help.
Sleeping
*
0 - I get no pain in bed.
1 - I get pain in bed, but it does not prevent me from sleeping well.
2 - Because of pain, my normal night’s sleep is reduced by less than 1/4.
3 - Because of pain, my normal night’s sleep is reduced by less than 1/2.
4 - Because of pain, my normal night’s sleep is reduced by less than 3/4.
5 - Pain prevents me from sleeping at all.
Lifting
*
0 - I can lift heavy weights without extra pain.
1 - I can lift heavy weights, but it causes extra pain.
2 - Pain prevents me from lifting heavy weights off the floor.
3 - Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g., on a table.
4 - Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.
5 - I can only lift very light weights, at the most.
Sitting
*
0 - I can sit in any chair as long as I like without any pain.
1 - I can only sit in my favorite chair as long as I like.
2 - Pain prevents me from sitting more than one hour.
3 - Pain prevents me from sitting more than 1⁄2 hour.
4 - Pain prevents me from sitting more than 10 minutes.
5 - Pain prevents me from sitting at all.
Traveling
*
0 - I get no pain while traveling.
1 - I get some pain while traveling, but none of my usual forms of travel make it any worse.
2 - I get extra pain while traveling, but it does not compel me to seek alternative forms of travel.
3 - I get extra pain while traveling which compels me to seek alternative forms of travel.
4 - Pain restricts all forms of travel.
5 - Pain prevents me from travel except that done lying down.
Standing
*
0 - I can stand as long as I want without pain.
1 - I have some pain while standing, but it does not increase with time.
2 - I cannot stand for longer than one hour without increasing pain.
3 - I cannot stand for longer than 1⁄2 hour without increasing pain.
4 - I cannot stand for longer than ten minutes without increasing pain.
5 - I avoid standing because it increases the pain straight away.
Social Life
*
0 - My social life is normal and gives me no pain.
1 - My social life is normal, but increases the degree of my pain.
2 - Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc.
3 - Pain has restricted my social life and I do not go out very often.
4 - Pain has restricted my social life to my home.
5 - I have hardly any social life because of the pain.
Walking
*
0 - Pain does not prevent me from walking any distance.
1 - Pain prevents me from walking more than a mile.
2 - Pain prevents me from walking more than 1⁄2 mile.
3 - Pain prevents me from walking more than 1⁄4 mile.
4 - I can only walk while using a cane or crutches.
5 - I am in bed most of the time and have to crawl to the toilet.
Changing Degree of Pain
*
0 - My pain is rapidly getting better.
1 - My pain fluctuates, but overall is definitely getting better.
2 - My pain seems to be getting better, but improvement is slow at present.
3 - My pain is neither getting better or worse.
4 - My pain is gradually worsening.
5 - My pain is rapidly worsening.
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