• Oswestry Disability Index Questionnaire

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Please Read:
    This questionnaire is designed to give your physician information as to how your back pain has affected your ability to manage relate to you. Please only mark the ONE box which most closely describes everyday life. Please answer every section, and mark in each section your current condition on only the one box that best describes your problem.

  • Section 1 – Pain Intensity*
  • Section 2 – Personal Care (Washing, Dressing, etc.)*
  • Section 3 – Lifting*
  • Section 4 - Walking*
  • Section 5 - Sitting*
  • Section 6 – Standing*
  • Section 7 – Sleeping*
  • Section 8 – Sex Life*
  • Section 9 – Traveling*
  • Section 10 – Employment/Homemaking*

  • Intracept™ Procedure Patient Intake Form

  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Duration of low back pain: (circle one)*

  • Complete the remainder of the form considering your pain and function over the last 30 days

  • 0-10 NUMERIC PAIN RATING SCALE

  • Does bending forward/lifting increase your back pain? (circle one)*
  • Does sitting for long periods (ex. driving) increase your back pain? (circle one)*
  • Does walking and/or standing improve your back pain? (circle one)*
  • Does your pain negatively affect your activities of daily living? (check all that apply)
  • Which treatments have your tried to relieve your low back pain? (check all that apply)*
  • Should be Empty: