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Download & Print Form - Coykendall Chiropractic Office 2026

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4.8 out of 5

131 votes

The document is a Modified Oswestry Low Back Pain Questionnaire designed to assess the impact of low back pain on daily activities. It includes various sections where patients rate their pain intensity and its effects on personal care, lifting, walking, sitting, standing, sleeping, social life, traveling, and employment/homemaking. Additionally, it collects patient medical information and outlines billing policies, privacy practices, and informed consent for diagnostic procedures like EMG/NCS testing.

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Click 'Get Form' to open it in the editor.
Begin by entering your name and date at the top of the form. This personal information is essential for identification.
Proceed to the Modified Oswestry Low Back Pain Questionnaire. For each section, carefully read the statements and select one option that best describes your experience by marking a circle.
Fill out the Patient Medical Information section, providing details such as gender, how you heard about the office, education level, and employment status.
Complete the General Health Status and Social/Health Habits sections by checking the appropriate boxes regarding your health and lifestyle choices.
In the Current Conditions/Chief Complaints section, specify your reason for visiting and when your problem started.
Review the Medical/Surgical History section thoroughly, checking any relevant medical conditions or surgeries you've had.
Finally, read through the Billing, Privacy & Informed Consent sections carefully before signing at the bottom to acknowledge understanding.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (131 Votes)

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Download & Print Form - Coykendall Chiropractic Office 2026

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