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Lumbar Screening  Form

Lumbar Screening Form

Use a lumbar spine template to make your document workflow more streamlined.

Stenosis, are symptoms severe enough that surgery would be  No  Not Applicable considered?  Yes Duration of symptoms  Less than 6 weeks  6 to 12 weeks  Greater than 12 weeks Back Dominant Pain (Pain above gluteal fold and below the T12 rib)  Back Dominant Pain OR Leg Dominant Pain, Sensory Radiculopathy (Below the gluteal fold, specific root distribution and Radiation below the knee)  Leg Dominant Pain Objective Motor Weakness in Lower Extremity on Examination  Yes  No Typical...
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