Your care team may ask you to fill out one of these short questionnaires before a visit. They measure how back pain or other health problems affect your daily life. Each form adds up your score for you as you answer. Comparing scores over time helps you and your provider see how you are responding to treatment.
Oswestry Disability Index (ODI)
10 sections about how back or leg pain affects pain level, personal care, lifting, walking, sitting, standing, sleep, sex life, social life and travel. Takes about 5 minutes.
Score: 0% to 100%. Lower is better.
Start the ODI →PROMIS Physical Function and Pain Interference
16 questions in two parts: what you are able to do physically, and how much pain got in the way of your life in the past 7 days. Takes about 5 minutes.
Score: T-scores, where 50 is the US average.
Start the PROMIS forms →PROMIS Global-10
10 questions about your overall physical health, mental health, social life, fatigue and pain. Takes about 2 to 3 minutes. A printable paper version is on the form page.
Score: Global Physical Health and Global Mental Health T-scores, where 50 is the US average.
Start the PROMIS Global-10 →WOMAC Osteoarthritis Index
24 questions about pain, stiffness and daily activities for a hip or knee with arthritis, over the past 48 hours. Takes about 5 to 10 minutes.
Score: 0 to 96 (also shown as a percentage). Lower is better.
Start the WOMAC →Roland-Morris Low Back Pain and Disability Questionnaire
24 yes-or-no statements about how your back affects daily life today. Takes about 5 minutes.
Score: 0 to 24 (number of Yes answers). Lower is better.
Start the Roland-Morris form →Procedure forms
Print-and-sign forms for procedures done at GSMC. Read the form, fill in your name if you like, then sign on the screen with a finger, stylus or mouse, or print it and sign in pen. Save the signed form with Print / Save as PDF. You can also press Submit to send the signed form to our office.
Procedure Consent Form
Informed consent for an injection or other pain procedure: alternatives, benefits, general and specific risks, and signature lines.
Open the consent form →Discharge Instructions / Home Care After Your Procedure
Injection site care, activity, diet, what to expect, when to call the doctor, and signature lines.
Open the discharge instructions →Knee Brace Packet
Knee orthosis (L1833) acknowledgment and order, plus the Medicare Advance Beneficiary Notice (ABN), with signature lines.
Open the knee brace packet →Back, Shoulder, Wrist, Ankle and Neck Brace Packet
Brace order sheet, an acknowledgment page for each brace given (back, shoulder, wrist, neck, ankle walking boot), and the Medicare ABN.
Open the brace packet →How to use these forms
- Answer every question based on how you are now (or in the past 7 days, where the question says so).
- Your score updates as you answer.
- When you finish, choose Print / Save as PDF. Bring the printout to your appointment, or show the PDF to our staff.
- When you press Submit, your form is sent securely to our office. Nothing is sent unless you press Submit.
These scores do not diagnose a condition. Your provider will review them with you. If you have questions, call us at 732-202-3000.