Back Form

The safety of our employees and their family, our patients, are paramount above all else. As we learn more about the novel coronavirus and the disease it cases (COVID-19), we all have to do our part to limit its spread. We reply on guidance from the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and local health officials to guide our health and safety precautions as we continue to operate as an essential business that’s part of the nation’s critical infrastructure.

To that aim, Water & Sports Physical Therapy has implemented enhanced screening of all employees and patients who come to a WSPT clinic. Your honest participation in this process is critical to maintaining everyone’s well being during this time.

Please answer the questions listed before coming in for your appointment.

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Modified Oswestry Low Back Pain Disability Questionnaire

This questionnaire has been designed to give your therapist information as to how your back pain has affected your ability to manage in everyday life. Please answer every question by placing a mark in the one box that best describes your condition today. We realized you may feel that two of the statements may describe your condition, but please mark only the box that most close describes your current condition.

Pain Intensity

I can tolerate the pain I have without having to use pain medication.

The pain is bad, but I can manage without having to take pain medication.

Pain medication provides me with complete relief from pain.

Pain medication provides me with moderate relief from pain.

Pain medication provides me with little relief from pain.

Pain from medication has no effect on my pain.

Personal Care (e.g., Washing, Dressing)

I can take care of myself normally without causing increased pain.

I can take care of myself normally, but it increases my pain.

It is painful to care of myself, and I am slow and careful.

I need help every day in most aspects of my care.

I do not get dressed, I wash with difficulty, and I stay in bed.

Lifting

I can life heavy weights without increased pain.

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

Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned.

I can lift only very light weights.

I cannot lift or carry anything at all.

Walking

Pain does not prevent me from walking any distance.

Pain prevents me from walking more than 1 mile (1 mile = 1.6 km).

Pain prevents me from walking more than 1/2 mile.

I can walk only with crutches or a cane.

I am in bed most of the time and have to crawl to the toilet.

Sitting

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 for more than 1 hour.

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

Pain prevents me from sitting for more than 10 minutes.

Pain prevents me from sitting at all.

Standing

I can stand as long as I want without increased pain.

I can stand as long as I want, but it increases my pain.

Pain prevents me from standing for more than 1 hour.

Pain prevents me from standing for more than 1/2 hour.

Pain prevents me from standing for more than 10 minutes.

Pain prevents me from standing at all.

Sleeping

Pain does not prevent me from sleeping well.

I can sleep well only by using pain medication.

Even when I take medication, I sleep less than 6 hours.

Even when I take medication, I sleep less than 4 hours.

Even when I take medication, I sleep less than 2 hours.

Pain prevents me from sleeping at all.

Social Life

My social life is normal and does not increase my pain.

My social life is normal, but it increases my level of pain.

Pain prevents me from participating in more energetic activities (e.g., sports, dancing).

Pain prevents me from going out very often.

Pain has restricted my social life to my home.

I have hardly any social life because of my pain.

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 under 1/2 hour.

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

Employment/Homemaking

My normal homemaking/job activities does 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 (e.g., 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.

Patient Name*

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Date*

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Which location are you going to?*

Back Form

Modified Oswestry Low Back Pain Disability Questionnaire

CARMEL VALLEY

CARMEL VALLEY (POOL)

CORONADO

CORONADO (POOL)

MISSION BEACH

MISSION BEACH (POOL)

DOWNTOWN

DOWNTOWN (POOL)

SCRIPPS RANCH

Scripps Ranch Pool

POWAY

LA JOLLA

UTC

SDCST