Referral criteria CORE back tool
Rehabilitation referral criteria (4-12 treatments): [checklist name="variable_1" value="Absence of red flags|Pain is managed well so that patient can tolerate treatment|Pain has mechanical directional preference – varies with movement, position or activity|Patient is ready to be an active partner in goal setting and self management"] Surgical referral criteria: [checklist name="variable_2" value="Failure to respond to evidence based compliant conservative care of at least 12 weeks|Unbearable constant leg dominant pain|Worsening nerve irritation tests (SLR or femoral nerve stretch)|Expanding motor, sensory or reflex deficits|Recurrent disabling sciatica|Disabling neurogenic claudication"] Specialist referral: [checkbox name="variable_3" value="Physiatry|Cognitive Behavioural Therapy|Pain specialist|Multidisciplinary Pain Clinic|Rheumatologist|Other:"] [text size-50]
There are 4 form elements.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.75, 4 form elements, 10 boilerplate words, 1 text boxes, 1 checkboxes, 2 check lists, 17 total clicks
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