Skip to content

Reviews
Booking
insurance Booking
About Marc
Modalities
Contact

(720)614-9847
Services Provided in Freeland, Wa at:
Dr. Eli Bentabou Chiropractic & Wellness
1705 Main Street, Freeland, Wa 98249

Reviews
Booking
insurance Booking
About Marc
Modalities
Contact

Disability Index

June 17, 2026 / Marc Juneau / Comments Off on Disability Index

Revised Oswestry Disability Index

Back-pain disability questionnaire with automatic core Gravity Forms scoring.

1Sections 1-2

2Sections 3-4

3Sections 5-6

4Sections 7-8

5Sections 9-10

Name

This field is for validation purposes and should be left unchanged.

Instructions: Answer every section and choose only the one statement that most closely describes your situation. Each choice is scored from 0 to 5. The calculated score is stored with the entry for clinical review.

Patient Name(Required)

Section 1 – Pain Intensity

Section 1 – Pain Intensity(Required)

The pain comes and goes and is very mild.

The pain is mild and does not vary much.

The pain comes and goes and is moderate.

The pain is moderate and does not vary much.

The pain comes and goes and is very severe.

The pain is severe and does not vary much.

Section 2 – Personal Care

Section 2 – Personal Care(Required)

I would not have to change my way of washing or dressing in order to avoid pain.

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

Washing and dressing increases the pain, but I manage not to change my way of doing it.

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

Because of the pain, I am unable to do some washing and dressing without help.

Because of the pain, I am unable to do any washing and dressing without help.

Section 3 – Lifting

Section 3 – Lifting(Required)

I can lift heavy weights without extra pain.

I can lift heavy weights, but it causes extra pain.

Pain prevents me from lifting heavy weights off the floor, but I manage if they are conveniently positioned, such as on a table.

Pain prevents me from lifting heavy weights off the floor.

Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.

I can only lift very light weights at the most.

Section 4 – Walking

Section 4 – Walking(Required)

I have no pain on walking.

I have some pain on walking, but it does not increase with distance.

I cannot walk more than one mile without increasing pain.

I cannot walk more than one-half mile without increasing pain.

I cannot walk more than one-quarter mile without increasing pain.

I cannot walk at all without increasing pain.

Section 5 – Sitting

Section 5 – Sitting(Required)

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

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

Pain prevents me from sitting more than one hour.

Pain prevents me from sitting more than one-half hour.

Pain prevents me from sitting more than 10 minutes.

I avoid sitting because it increases pain right away.

Section 6 – Standing

Section 6 – Standing(Required)

I can stand as long as I want without pain.

I have some pain on standing, but it does not increase with time.

I cannot stand for longer than one hour without increasing pain.

I cannot stand for longer than one-half hour without increasing pain.

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

I avoid standing because it increases the pain right away.

Section 7 – Sleeping

Section 7 – Sleeping(Required)

I get no pain in bed.

I get pain in bed, but it does not prevent me from sleeping well.

Because of pain, my normal night’s sleep is reduced by less than one-quarter.

Because of pain, my normal night’s sleep is reduced by less than one-half.

Because of pain, my normal night’s sleep is reduced by less than three-quarters.

Pain prevents me from sleeping at all.

Section 8 – Social Life

Section 8 – Social Life(Required)

My social life is normal and gives me no pain.

My social life is normal, but increases the degree of pain.

Pain has no significant effect on my social life apart from limiting my more energetic interests, such as dancing.

Pain has restricted my social life and I do not go out very often.

Pain has restricted my social life to my home.

I have hardly any social life because of the pain.

Section 9 – Traveling

Section 9 – Traveling(Required)

I get no pain while traveling.

I get some pain while traveling, but none of my usual forms of travel makes it any worse.

I get extra pain while traveling, but it does not compel me to seek alternative forms of travel.

I get extra pain while traveling, which compels me to seek alternative forms of travel.

Pain restricts all forms of travel.

Pain prevents all forms of travel except that done lying down.

Section 10 – Changing Degree of Pain

Section 10 – Changing Degree of Pain(Required)

My pain is rapidly getting better.

My pain fluctuates, but is definitely getting better.

My pain seems to be getting better, but improvement is slow at present.

My pain is neither getting better nor worse.

My pain is gradually worsening.

My pain is rapidly worsening.

Scoring (Administrative)

Subscribe to our Mailing List for specials and Offers from Whidbey Massage Therapy!

Name

Please enter your name.

Email Address

Please enter a valid email address.

Thanks for subscribing! Please check your email for further instructions.

Something went wrong. Please check your entries and try again.

Posted in

Marc Juneau

Posts navigation

← TEMP Whidbey Massage Therapy

Pain Assessment →

What does relaxation
look like to you?

main line: (360) 217-9300
fax: 206-900-8439
cell: 720-614-9847

AMTA - Certificate of Insurance

Home Studio incall, outcall at your location or at
Dr. Eli Bentabou Chiropractic & Wellness
1705 Main Street, Freeland, Wa 98249

Leave a Google Review!

PAY FOR MASSAGE SERVICES OR TIP MANUALLY VIA CC