Modified Oswestry – Low Back Questionnaire

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Step 1 of 2

  • Date of Birth
  • Today's Date of Service
  • The number of visits the patient has done up to that point with the starting date the same as the first date their Dx was on the patients chart
  • All forms are to be filled prior to service. Example calculation for number of days: Friday was the patients last visit, Monday is when the patient fills this out again. The answer is 3 days.