1. What are this client’s presenting symptoms likely due to?
a. A problem in the back?
	Yes	No
b. Is it likely a medical problem (eg, genitourinary, systemic)?
	Yes	No
c. Is it likely a mechanical/degenerative problem from elsewhere (eg, hip, knee)?
	Yes	No
List:–––––––––––––––––––––––––––––
2. Is there likely a spinal cord or cauda equina lesion?
	Yes	No
Back pain diagnostic triage
3. Indicate which category best fits the clinical presentation:
a. Possible serious spinal pathology
	Yes	No
b. Nerve root problem
	Yes	No
c. Non-specific back pain
	Yes	No
4. Indicate what the likely source of the nerve root problem is:
a. none	Yes	No
b. discogenic	Yes	No
c. stenosis	Yes	No
Management recommendations
6. Indicate what your recommended treatment plan is (check all that apply)
a. No further follow-up	Yes	No
b. Urgent surgical consult	Yes	No
c. Emergency surgical consult	Yes	No
d. Referral to another specialist	Yes	No
List: _________________
e. Physiotherapy/rehabilitation (with or without PT consultant review)	Yes	No
f. PT treatment and surgical referral	Yes	No
g. Advanced imaging (ie, CT or MRI)	Yes	No

Abbreviations: PT, physiotherapist; CT, computed tomography; MRI, magnetic resonance imaging.