Would you like to switch to the accessible version of this site?

Go to accessible site Close modal window

Don't need the accessible version of this site?

Hide the accessibility button Close modal window

Accessibility View Close toolbar

(760) 741-2805

LOCATION

801 South Escondido Blvd.

Escondido, CA

Menu

Home
About Us
New Patients
Services
Patient Resources
Patient Education
- All Articles
Contact Us
Schedule Appointment

Back Oswestry

Back Index Form

Patient Name*

Date*

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.

Pain Intensity*

Please select one option

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 very severe.

5. The pain is very severe and does not vary much.

Personal Care*

Please select one option

0. I do not have to change my way of washing or 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 and dressing without help.

Sleeping*

Please select one option

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 sleep is reduced by less than 25%.

3. Because of pain my normal sleep is reduced by less than 50%.

4. Because of pain my normal sleep is reduced by less than 75%.

5. Pain prevents me from sleeping at all.

Lifting*

Please select one option

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 off the floor, but I can manage light to medium weights if they are conveniently positioned.

5. I can only lift very light weights.

Sitting*

Please select one option

0. I can sit in any chair as long as I like.

1. I can only sit in my favorite chair as long as I like.

2. Pain prevents me from sitting more than 1 hour.

3. Pain prevents me from sitting more than 1/2 hour.

4. Pain prevents me from sitting more than 10 minutes.

5. I avoid sitting because it increases pain immediately.

Standing*

Please select one option

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 more than 1 hour without increasing pain.

3. I cannot stand for longer than 1/2 hour without increasing pain.

4. I cannot stand for longer than 10 minutes without increasing pain.

5. I avoid standing because it increases pain immediately.

Walking*

Please select one option

0. I have no pain while walking.

1. I have some pain while walking but it doesn't increase with distance.

2. I cannot walk more than 1 mile without increasing pain.

3. I cannot walk more than 1/2 mile without increasing pain.

4. I cannot walk more than 1/4 mile without increasing pain.

5. I cannot walk at all without increasing pain.

Traveling*

Please select one option

0. I get no pain while traveling.

1. I get some pain while traveling but none of my usual forms of travel make it worse.

2. I get extra pain while traveling but it does not cause me to seek alternate forms of travel.

3. I get extra pain while traveling which causes me to seek alternate forms of travel.

4. Pain restricts all forms of travel except that done while lying down.

5. Pain restricts all forms of travel.

Social Life*

Please select one option

0. My social life is normal and gives me no extra pain.

1. My social life is normal but increases the degree of 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.

Changing Degree of Pain*

Please select one option

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.

3. My pain is neither getting better or worse.

4. My pain is gradually worsening.

5. My pain is rapidly worsening.

Thank you for taking the time to fill out this form.

Contact Us

Send Us An Email Today!

Error!

Our Location

801 South Escondido Blvd | Escondido CA, 92025

Office Hours

Find Out When We Are Open

Monday:

8:00 am-6:00 pm

Tuesday:

9:00 am-5:00 pm

Wednesday:

8:00 am-6:00 pm

Thursday:

9:00 am-12:00 pm

Friday:

8:00 am-6:00 pm

Saturday:

Closed

Sunday:

Closed

Copyright © 2026 MH Sub I, LLC dba Baystone Media
Admin Log In
Site Map
Terms Of Use
Privacy Policy