OSWESTRY DISABILITY INDEX

Date: [Date]
Patient: [Name or ID, age, occupation]
Encounter: [New patient, re-evaluation, before surgery, weeks after surgery, or discharge]
Form used: [ODI version 2.1a or 2.1b, or modified Oswestry; language; paper, tablet, or portal]

PRESENTATION
Main complaint: [Low back pain, leg pain, or both, and which is worse]
Leg symptoms: [Side, how far down the leg, numbness, weakness, walking limit, or none]
Diagnosis: [Working diagnosis, and imaging if done]
Care to date: [Exercise, therapy, medicines, injections, or surgery, with dates]

CALCULATION
Sections answered: [Number out of 10, and which were blank]
Section scores: [Pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, travelling: each 0 to 5]
Raw total: [Sum of the section scores]
Possible total: [50, less 5 for each blank section]
ODI: [Raw total divided by possible total, times 100, to the nearest whole percent]
Band: [Minimal, moderate, severe, disabling, or bed-bound or overstated]

PROGRESS
First ODI: [Date and percent]
Previous ODI: [Date and percent]
Change from first: [Points and percent of the first score; meaningful at 10 points or 30 percent]

RED FLAGS AND EXAM
Red flags: [Bladder or bowel change, saddle numbness, progressive weakness, fever, weight loss, cancer history: present or absent]
Neurological exam: [Strength, reflexes, sensation, straight leg raise]
Function seen today: [Sitting tolerance, walking distance, transfers, as observed]

DECISION
Management: [Continue, progress, change treatment, inject, refer, operate, or discharge]
Goal: [Target ODI and the activity it stands for, with a date]
Work and activity: [Full duties, modified duties, or off work, with any limits]
Next ODI: [Date or interval]

Clinician: [Name, credentials]