Your Legal Representative ie Solicitor
Have you suffered a road traffic accident ?*
Have you suffered an injury ?*
Have you had inappropriate treatment ? (ie surgery)*
Please describe your problems ie pain, stiffness, limp, weakness, numbness etc
Please describe where your pain is :
Please describe any symptoms that you had before the incident
Please list all the medications that you are taking as a result of the incident (do not include general medications unrelated to incident)
Please describe whether you have had physio or osteopathy and how many sessions since the incident.
What makes your symptoms better or worse
What daily activities can’t you do ?.
Have your mood and feelings been affected ?
Oswestry Disability Questionnaire
This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realise you may consider that two or more statements in any one section apply, but please just select one that indicates the statement which most clearly describes your problem.
Section 1 – Pain Intensity *
0. I have no pain at the moment.1 The pain is very mild at the moment.2 The pain is moderate at the moment.3 The pain is fairly severe at the moment.4 The pain is very severe at the moment.5 The pain is the worse imaginable at the moment.
Section 2 – Personal Care (Washing, dressing, etc.)
0. I can look after myself normally without causing extra pain.2 It is painful to look after myself and I am slow and careful.3. I need some help but can manage most of my personal care4. I need help every day in most aspects of self care5. I do not get dressed, wash with difficulty and stay in bed.
Section 3 – Lifting*
0. I can lift heavy weights without extra pain.1. I can lift heavy weights but it gives extra pain.2. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned for example on a table.3. Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned4. I can only lift very light weights5. I cannot lift or carry anything at all.
Section 4: Walking
Pain does not prevent me walking any distancePain prevents me from walking more than 1 milePain prevents me from walking more than ½ milePain prevents me from walking more than 100 yardsI can only walk using a stick or crutchesI am in bed most of the time
Section 4: Walking
My sleep is never disturbed by painMy sleep is occasionally disturbed by painBecause of pain I have less than 6 hours sleepBecause of pain I have less than 4 hours sleepBecause of pain I have less than 2 hours sleepPain prevents me from sleeping at all
Please enter two digits with no spaces (Example: 12)*