Kettering Health Network

April 06, 2020
Date of completion

Clinician's name (or ref)

Patient's name (or ref)

Please answer each section below by choosing the choice that applies the most to you at this time.

I have "Chronic Pain" or pain that has bothered me for 3 months or more:
Yes No

Choose one of the following:

Prior to Surgery
After Surgery 3 Months
After Surgery 1 year

After Surgery 6 weeks
After Surgery 6 Months
After Surgery 2 years

Please answer each section below by choosing the choice that applies the most to you at this time.

Section 1: Pain Intensity		Section 6: Standing
	I have no pain at the moment.		I can stand as long as I want without extra pain.
	The pain is very mild at the moment.		I can stand as long as I want but it gives me extra pain.
	The pain is moderate at the moment.		Pain prevents me from standing for more than 1 hour.
	The pain is fairly severe at the moment		Pain prevents me from standing for more than 30 minutes.
	The pain is very severe at the moment.		Pain prevents me from standing for more than 10 minutes.
	The pain is the worst imaginable at the moment.		Pain prevents me from standing at all.

Section 2: Personal Care		Section 7: Sleeping
	I can look after myself normally without causing extra pain.		My sleep is never disturbed by pain.
	I can look after myself normally but it is painful.		My sleep is occasionally disturbed by pain.
	It is painful to look after myself and I am slow and careful.		Because of pain I have less than 6 hours sleep.
	I need some help but manage most of my personal care.		Because of pain I have less than 4 hours sleep.
	I need help every day in most aspects of self care.		Because of pain I have less than 2 hours sleep.
	I do not get dressed, wash with difficulty and stay in bed.		Pain prevents me from sleeping at all.

Section 3: Lifting		Section 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 floor but I can manage if they are conveniently positioned for example on a table.		Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing, etc.
	Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned.		Pain has restricted my social life and I do not go out as often.
	I can lift only very light weights.		Pain has restricted social life to my home.
	I cannot lift or carry anything at all.		I have no social life because of pain.

Section 4: Walking		Section 9: Traveling
	Pain does not prevent me walking any distance.		I can travel anywhere without pain.
	Pain prevents me walking more than 1 mile.		I can travel anywhere but it gives extra pain.
	Pain prevents me walking more than a quarter of a mile.		Pain is bad but I manage journeys over two hours.
	Pain prevents me walking more than a 100 yards.		Pain restricts me to journeys of less than one hour.
	I can only walk using a stick or crutches.		Pain restricts me to journeys of less than 30 minutes.
	I am in bed most of the time and have to crawl to the toilet.		Pain prevents me from traveling except to receive treatment.

Section 5: Sitting		Section 10: Changing Degree of Pain
	I can sit in any chair as long as I like.		My pain is rapidly getting better.
	I can only sit in my favorite chair as long as I like.		My pain fluctuates, but overall is definitely getting better.
	Pain prevents me sitting more than 1 hour.		My pain seems to be getting better, but improvement is slow at present.
	Pain prevents me from sitting more than 0.5 hours.		My pain is neither getting better nor worse.
	Pain prevents me from sitting more than 10 minutes.		My pain is gradually worsening.
	Pain prevents me from sitting at all.		My pain is rapidly worsening.

Oswestry Disabilty Index (ODI) Percent Disability Is: %

This page cannot be saved by us due to patient data protection so, before leaving this window, please print the filled in form for your records.

Interpreting ODI
0-20% (minimal disability):	Patients can cope with most activities of daily living. No treatment may be indicated except for suggestions on lifting, posture, physical fitness and diet. Patients with sedentary occupations (ex. secretaries) may experience more problems than others.
21-40% (moderate disability):	Patients may experience more pain and problems with sitting, lifting and standing. Travel and social life are more difficult. Patients may be off work. Personal care, sleeping and sexual activity may not be grossly affected. Conservative treatment may be sufficient.
41-60% (severe disability):	Pain is a primary problem for these patients, but they may also be experiencing significant problems in travel, personal care, social life, sexual activity and sleep. A detailed evaluation is appropriate.
61-80% (crippled):	Back pain has an impact on all aspects of daily living and work. Active treatment is required.

Reference for Score: Fairbank JC, Pynsent PB, The Oswestry Disability Index. Spine 2000; 25(22):2940-2952.