Revised Oswestry Index for Low Back Pain
Plexus Physical Therapy - Status Questionnaires

Please complete the following questionnaire to help us track your progress and identify how to best help you!

This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to mange everyday life. Please answer every section and mark in each section only the ONE box that applies to you. We realize that you may consider that two of the statements in any one section relate to you, but please just mark the box that most closely describes your problems.

Name
Your answer
Date
MM
/
DD
/
YYYY
Pain Intensity
Personal Care
Lifting
Walking
Sitting
Standing
Sleeping
Social Life
Travelling
Changing Degree of Pain
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