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  5. Oswestry Survey 1 - Backup070115,1012am
Exit Survey
 
 
Chicago Resident,
Is your back condition treatable with Non-Surgical Decompression? Complete the short 10-question anonymous pain survey and see your results at the end of the survey.
 
 
 
1) PAIN INTENSITY
At this moment, the pain is...
 
No pain
 
Very mild
 
Moderate
 
Fairly severe
 
Very severe
 
The worst imaginable
 
 
2) PERSONAL CARE 
Activities like washing, dressing etc
 
I can look after myself normally without causing extra pain
 
I can look after myself normally but it causes extra pain
 
It is painful to look after myself and I am slow and careful
 
I need some help but manage most of my personal care
 
I need help every day in most aspects of self-care
 
I do not get dressed, I wash with difficulty and stay in bed
 
 
3) LIFTING
 
I can lift heavy weights without extra pain
 
I can lift heavy weights but it gives extra pain
 
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently placed eg. on a table
 
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned
 
I can lift very light weights
 
I cannot lift or carry anything at all
 
 
4) WALKING
 
Pain does not prevent me walking any distance
 
Pain prevents me from walking more than 1 mile
 
Pain prevents me from walking more than 1/2 mile
 
Pain prevents me from walking more than 100 yards
 
I can only walk using a stick or crutches
 
I am in bed most of the time
 
 
5) SITTING
 
I can sit in any chair as long as I like
 
I can only sit on my favorite chair/sofa as long as I like
 
Pain prevents me sitting more than one hour
 
Pain prevents me from sitting more than 30 minutes
 
Pain prevents me from sitting more than 10 minutes
 
Pain prevents me from sitting at all
 
 
6) STANDING
 
I can stand as long as I want without extra pain
 
I can stand as long as I want but it gives me extra pain
 
Pain prevents me from standing for more than 1 hour
 
Pain prevents me from standing for more than 3 minutes
 
Pain prevents me from standing for more than 10 minutes
 
Pain prevents me from standing at all
 
 
7) SLEEPING
 
My sleep is never disturbed by pain
 
My sleep is occasionally disturbed by pain
 
Because of pain I have less than 6 hours sleep
 
Because of pain I have less than 4 hours sleep
 
Because of pain I have less than 2 hours sleep
 
Pain prevents me from sleeping at all
 
 
8) SEX LIFE
 
My sex life is normal and causes no extra pain
 
My sex life is normal but causes some extra pain
 
My sex life is nearly normal but is very painful
 
My sex life is severely restricted by pain
 
My sex life is nearly absent because of pain
 
Pain prevents any sex life at all
 
 
9) SOCIAL LIFE
 
My social life is normal and gives me no extra 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 eg, sports
 
Pain has restricted my social life and I do not go out as often
 
Pain has restricted my social life to my home
 
I have no social life because of pain
 
 
10) TRAVELLING
 
I can travel anywhere without pain
 
I can travel anywhere but it gives me extra pain
 
Pain is bad but I manage journeys over two hours
 
Pain restricts me to journeys of less than one hour
 
Pain restricts me to short necessary journeys under 30 minutes
 
Pain prevents me from travelling except to receive treatment
 
 
0.0 

YOUR SCORE: 0.0What does it mean?If you scored between...Your condition is...0-10: MINIMAL DISABILITY. You can cope with most living activities. Usually no treatment is needed. Proper lifting, sitting and exercise is advised.11-20: MODERATE DISABILITY. You experience more pain and difficulty with sitting, lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care, sexual activity and sleeping are not grossly affected. Quality of life is moderately affected. Conservative treatment is advised.21-30: SEVERE DISABILITY. Back pain is a fundamental part of your life with daily living activities significantly affected. Quality of life fundamentally impacted. Proper medical treatment is needed.31-40 CRIPPLED. Back pain impinges on all aspects of your life. Proper medical treatment is needed.41-50 BED BOUND. You are either bed bound or exaggerating your symptoms
 
 
 
Would you like to share the results of the survey with Dr. Taylor's office to get a FREE consultation on your condition?
 
Yes, please.
 
No, thank you.
 
 
Please provide you contact information:
First Name : 
Last Name : 
Phone : 
Email Address : 
 
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