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Low Back Pain and Disability Index Form

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Name*
First Last
Date*
MM slash DD slash YYYY
Phone
Email*

PLEASE READ CAREFULLY: This questionnaire has been designed to give the doctor information as to how your low back pain has affected your ability to manage everyday life. Please read all statements in each section and mark the circle which most describes your problem.
SECTION 1: PAIN INTENSITY*
- 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 severe and does not vary much.
SECTIONS 2: PERSONAL CARE*
- 0. I do not have to change my way of washing or dressing 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. Because of the pain, I am unable to do some washing and dressing without help.
- 4. Because of the pain, I am unable to do any washing or dressing without help.
SECTIONN 3: LIFTING*
- 0. I can lift heavy objects without any extra pain.
- 1. I can lift heavy objects, but it gives extra pain.
- 2. Pain prevents me from lifting heavy objects off the floor.
- 3. Pain prevents me from lifting heavy objects off the floor but I can manage if they are conveniently positioned on a table.
- 4. Pain prevents me from lifting heavy objects but I can manage light to medium objects.
- 5. I can only lift very light objects at the most.

SECTION 4: WALKING*
- 0. I have no pain on walking.
- 1. I have some pain but it does not increase with distance.
- 2. I cannot walk more than one 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.
SECTION 5: SITTING*
- 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 one hour.
- 3. Pain prevents me from sitting more than half an hour.
- 4. Pain prevents me from sitting more than 10 minutes.
- 5. I avoid sitting because it increases pain.
SECTION 6: STANDING*
- 0. I can stand as long as I want without pain.
- 1. I have some pain on standing but it does not increase with time.
- 2. I cannot stand for longer than one hour without increasing pain.
- 3. I cannot stand for longer than 1/2 hour without increasing pain.
- 4. I cannot stand longer than 10 minutes without increasing pain.
- 5. I avoid standing because it increases the pain.

SECTION 7: SLEEPING*
- 0. I get no pain in bed.
- 1. I get pain in bed but it does not prevent me from sleeping well.
- 2. Pain reduces my normal sleep by 1/4 each night.
- 3. Pain reduces my normal sleep by 1/2 each night.
- 4. Pain reduces my normal sleep by 3/4 each night.
- 5. Pain prevents me from sleeping at all.
SECTION 8: SOCIAL LIFE*
- 0. My social life is normal and gives me no pain.
- 1. My social life is normal but increases the degree of pain.
- 2. My social life is unaffected by pain apart from limiting more energetic interests.
- 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.
SECTION 9: DRIVING*
- 0. I get no pain while traveling.
- 1. I get some pain while traveling but none of my usual forms of travel make it any worse.
- 2. I get extra pain while traveling but it does not compel me to seek alternate forms of travel.
- 3. Pain restricts all forms of travel.
- 4. Pain prevents all forms of travel except that done lying down.
SECTION 10: CHANGING DEGREE OF PAIN*
- 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 at present.
- 3. My pain is neither getting better or worse.
- 4. My pain is gradually worsening.
- 5. My pain is rapidly worsening.

QUICK LOOK - ADMIN
LOW BACK PAIN SCALE*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
RATE YOUR PAIN ON A SCALE OF 0 - 10. 0 = ABSENCE OF PAIN 10 - EXTREME OPAIN
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BERLIN

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