OHSU

Self-Referral Tool

These questions can help you determine which OHSU Spine Center specialist to make an appointment with, to diagnose your spine issue. No one can see your answers, and they are not sent to the OHSU Spine Center.

Only a doctor can diagnose your medical condition. At the OHSU Spine Center, our spine specialists can examine and interview you to determine the cause of your pain and your treatment options. 

Seeing a doctor might give you different results from this questionnaire. If you’d like, you can print your questionnaire results and talk to the doctor about them.

Please note: All of the questions below are required. The submit button will activate when all the question have been answered.

Self-Referral Questions

Do you only have pain in your back or neck that does NOT extend to your arms or legs? Yes  No 
Have you experienced a recent onset of weakness, numbness or tingling in your arms or legs, or bowel or bladder incontinence? Yes  No 
Have you had your current symptoms for less than six months? Yes  No 
Have you had any prior conservative treatment, such as physical therapy, acupuncture or chiropractic treatment? Yes  No 
Have you had prior imaging (X-ray, MRI, CT scan, etc.) within the last year? Yes  No 
Have you ever had spine surgery? Yes  No 
Have you been taking narcotic pain medication (Oxycodone, Percocet, Dilaudid, morphine, etc.) for more than 90 days? Yes  No 

Disclaimer

Any medical or surgical advice provided in this Web site, even if intended to be accurate to the best of our knowledge, should be discussed with your medical or surgical practitioner. This Web site will serve to help direct you (the patient) to appropriate informational resources, and should not be considered a diagnosis. A diagnosis can only be given by an appropriate and experienced physician after interviewing and examining you (the patient). Only your physician or surgeon knows what is best for you. Always seek direct advice from your physician before embarking on any treatment, medication or therapy.  

Copyright 2002-2014 ©, Oregon Health & Science University. This document and the information contained within the document are not to be used or reproduced without written consent.