Pain, spine & orthopaedic care in Ocean & Monmouth County, NJ
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Disability/Consent/Discharge Forms

Oswestry Disability Index (ODI)

Ten short sections about how back or leg pain affects your everyday life. Your score updates as you answer.

Your answers stay on this device until you press Submit. If you press Submit, the completed form is sent over a secure connection and faxed to our office. You can also print the page or save it as a PDF instead.

Patient details
Needed if you submit the form to our office.

This questionnaire tells us how your back (or leg) trouble affects your ability to manage in everyday life. Please answer every section. Choose one statement in each section that most closely describes you today. If two statements seem to fit, choose the one that describes you best. If a section does not apply to you, you can skip it.

Your ODI score

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What your score means

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  • 0–20%Minimal disability
  • 21–40%Moderate disability
  • 41–60%Severe disability
  • 61–80%Very severe disability
  • 81–100%Bed-bound

How it is scored: each section is scored 0 to 5. Your score is the total of your answers divided by the highest possible total for the sections you answered (5 × number of sections answered), shown as a percentage. Lower scores mean less disability.

Send your form to our office

When your form is complete, press Submit. It is faxed securely to our office.

All forms

Oswestry Disability Index (ODI) version 2.1a. © Jeremy Fairbank, 1980. All rights reserved. US English version distributed by Mapi Research Trust. Score ranges from Fairbank JCT, Pynsent PB. The Oswestry Disability Index. Spine 2000;25(22):2940-2953. This form is for patients of Garden State Medical Center. It is not a diagnosis or medical advice.

Talk with a GSMC specialist

We will review your history and imaging and explain your options. Many plans, including Medicare, are accepted. We verify benefits before scheduling procedures.

Request an appointmentCall 732-202-3000