Form PHS-7061 Owestry Low Back Questionnaire

PHS-7061 (3/07)

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OMB No. xxxx-xxxx; OMB approval expires xx/xx/xx

PSC Graphics (301) 443-1090

EF

NAME

SOCIAL SECURITY NUMBER

(Continued)

Section 1 – Pain Intensity

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

The pain is bad but I manage without taking pain killers.

Pain killers give complete relief from pain.

Pain killers give moderate relief from pain.

Pain killers give very little relief from pain.

Pain killers have no effect on the pain and I do not use them.

Section 2 – Personal Care (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 everyday in most aspects of self care.

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

Section 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 fl oor, but I can manage if they are conveniently positioned, e.g., on table.

Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned.

I can lift only very light weights.

I cannot lift or carry anything at all.

REF: HEALTHCARE PROVIDER

AGE

DATE

GENDER

Male

Female

HOW LONG HAVE YOU HAD BACK PAIN?

HOW LONG HAVE YOU HAD LEG PAIN?

Years

Months

Weeks

Years

Months

Weeks

PROOF

PRIVACY ACT STATEMENT

AUTHORITY: 42 U.S.C. 202 et seq. and Executive Order 9397.

RECORDS SYSTEM: 09-40-0002, “PHS Commissioned Corps Medical Records,” HHS/PSC/HRS.

PRINCIPAL PURPOSE: To determine medical acceptability or update a medical fi le as part of the application process to the Commissioned

Corps of the U.S. Public Health Service.

ROUTINE USES: None.

DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper an applicant’s

candidacy. Use of the Social Security Number is used for positive identifi cation of records.

INSTRUCTIONS: Please complete the following questions regarding how your back pain has affected your ability to manage in everyday life. Please

answer every section, and mark in each section only the one box that applies to you. We realized you may consider that two of the statements in any one

section may relate to you, but please just mark the box which most closely describes your problem.

Note: It is intended that this form be completed online as a link to a ‘Yes’ answer on Item 53 of form PHS-7060, Report of Medical History. In the event an

applicant to the Commissioned Corps of the U.S. Public Health Service cannot complete this form online, the applicant must complete the form in paper

format and mail it to the Offi ce of Commissioned Corps Operations at the above address and mark envelope “To be Opened by Medical Personnel Only.”

If more space is needed (for versions of this form without expandable fi elds), please use the applicable area on page 3.

Department of Health and Human Services

Commissioned Corps of the U.S. Public Health Service

Offi ce of Commissioned Corps Operations

ATTN: Medical Evaluations Offi cer

Suite 100, Plaza Level

1101 Wootton Parkway

Rockville, MD 20852

OWESTRY LOW BACK QUESTIONNAIRE

The public reporting burden for this collection of information is estimated

to average 10 minutes per response, including the time for reviewing in-

structions, searching existing data sources, gathering and maintaining the

data needed, and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspect of this

collection of information, including suggestions for reducing the burden, to

the HHS / OS Reports Clearance Offi cer, 200 Independence Avenue, SW,

Room 537-H, Washington, DC 20012 (PRA 0990-XXXX). Respondents

should be aware that notwithstanding any other provision of law, no person

shall be subject to any penalty for failing to comply with a collection of infor-

mation if it does not display a currently valid OMB control number.

PHS-7061 (3/07)

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OWESTRY LOW BACK QUESTIONNAIRE

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Section 4 – Walking

Pain does not prevent me from 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 1/4 mile.

I can only walk using a stick or crutches.

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

Section 5 – 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.

Section 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 30 minutes.

Pain prevents me from standing for more than 10 minutes.

Pain prevents me from standing at all.

Section 7 – Sleeping

Pain does not prevent me from sleeping well.

I can sleep well only by using tablets.

Even when I take tablets I have less than 6 hours sleep.

Even when I take tablets I have less than 4 hours sleep.

Even when I take tablets I have less than 2 hours sleep.

Pain prevents me from sleeping at all.

Section 8 – Sex Life

My sex life is normal and causes no extra pain.

My sex life is normal and 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.

Section 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 signifi cant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc.

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.

(Continued)

PROOF

PHS-7061 (3/07)

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OWESTRY LOW BACK QUESTIONNAIRE

(Continued)

Section 10 – Traveling

I can travel anywhere without extra pain.

I can travel anywhere but it gives me extra pain.

Pain is bad but I can manage journeys over 2 hours.

Pain restricts me to journeys of less than 1 hour.

Pain restricts me to short necessary journeys under 30 minutes.

Pain prevents me from traveling except to the doctor or the hospital.

COMMENTS:

PROOF