OSWESTRY Intake Form | Pro-Motion Physical Therapy

MODIFIED OSWESTRY DISABILITY SCALE Initial Visit

Patient Name:

ID #

Date

Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability. Please select the answers below that best apply.

No pain = 0, Severe Pain = 10

Please rate your pain level with activity

MODIFIED OSWESTRY DISABILITY SCALE Initial Visit

9. Traveling

I can travel anywhere without increased pain.

I can travel anywhere, but it increases my pain.

My pain restricts my travel over 2 hours.

My pain restricts my travel over 1 hour.

My pain restricts my travel to short necessary journeys journeys under 1/2 hour

My pain prevents all travel except for visits to the physician/therapist or hospital.

10. Employment / Homemaking

My normal homemaking/job activities do not cause pain.

My normal homemaking/job activities increase my pain, but I can still perform all that is required of me

I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (eg, lifting, vacuuming).

Pain prevents me from doing anything but light duties.

Pain prevents me from doing even light duties.

Pain prevents me from performing any job or homemaking chores.

Cancer

Diabetes

Heart Condition

High Blood Pressure

Multiple Treatment Areas

Neurological Disorders (e.g., Parkinson's, Muscular Dystrophy, Huntington's, CVA, Alzheimer’s, TBI)

Obesity

Surgery for this Problem

High Blood Pressure

Systemic Disorders (e.g., Lupus, Rheumatoid Arthritis, Fibromyalgia)

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