MODIFIED OSWESTRY DISABILITY SCALE Initial Visit

Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability. Please select the answers below that best apply.

No pain = 0, Severe Pain = 10

Please rate your pain level with activity
1. Pain Intensity
2. Personal Care (washing, dressing, etc.)
3. Lifting
4. Walking
5. Sitting
6. Standing
7. Sleeping
8. Social Life

Pro Motion Physical Therapy 2006 W. Lincoln Ave. Ste. A, Yakima, WA 98902 509-573-4816

MODIFIED OSWESTRY DISABILITY SCALE Initial Visit

9. Traveling
10. Employment / Homemaking
ODI © Jeremy Fairbank 1980, All rights reserved. ODI contact information and permission to use: MAPI Research Trust, Lyon, France. E-mail: contact@mapi-trust.org – Internet: www.mapi-trust.org

Therapist Use Only

Comorbidities:

Pro Motion Physical Therapy 2006 W. Lincoln Ave. Ste. A, Yakima, WA 98902 509-573-4816

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  PATIENT INTAKE FORM

For your convenience you may print out the forms and bring them with you to your appointment or you may fill them out on line. If you choose to fill them out on line please remember to click submit and the forms will be sent directly to our clinic. Thank you.

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