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You are here: Range Of Services >> Spine >> Our service >> questionnaire >> lumbar spine

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lumbar spine/cervical spine

Title

Prename *

Last name *

Birth date *

No

Post code

City

Phone

E-Mail *

* obligatory

Address

1. Where do you have pain?

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Page 1 of 12

no pain perceptible

Front

Back

2. Where do you feel numbness?

Page 2 of 12

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no numbness perceptible

Front

Back

3. Where do you feel a loss of strength?

Page 3 of 12

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no loss of strength perceptible

Front

Back

5. Where do you feel most of the pain?

Page 4 of 12

Neck

left

right

Shoulder

left

right

Arm

left

right

Back

left

right

Buttocks

left

right

Leg

left

right

4. Since when have you suffered from your current complaints?

Pain:

Numbness:

Loss of strength:

6. Was there a cause for the beginning of your complaints? (Accident, heavy lifting etc.)

7. Have your complaints occured slowly without any reason?

Page 5 of 12

yes

yes

yes

no

no

8. Pain occurs during

Page 6 of 12

Lying

no

a little

strongly

no

a little

strongly

Sitting

Standing

no

a little

strongly

Walking

no

a little

strongly

Turning

no

a little

strongly

Bending over

no

a little

strongly

Lifting

no

a little

strongly

other activities:

9. When do you have most of your complaints?

Page 7 of 12

During

other activities:

Lying

Sitting

Standing

Walking

Turning

Bending over

Lifting

10. Coughing, sneezing or pressing worsens the pain

12. Have there been any imaging examinations?

11. Has a diagnosis been made? If yes, which?

no

MRI

Page 8 of 12

CT

a little

no

You can upload your medical report here

yes

strongly

or you can mail (info@betaklinik.de) or fax (+49 (0)228 909075-11) it.

other activities:

no

13. Do you suffer from diabetes mellitus?

14. Have you ever undergone spine surgery? If yes, which kind of surgery and what was the result?

Page 9 of 12

yes

yes

no

I don´t know

no

15. Which further treatments have been made to eliminate your complaints and what was the result?

Page 10 of 12

There have been no further treatments.

16. Other information:

17. Do you want a cost estimate?

Page 11 of 12

yes

no

19. Summary

Page 12 of 12

Send a copy

Title:

Prename:

Last name:

Birth date:

Phone:

E-Mail:

Address:

Post Code and City:

4. Since when have you suffered from your current complaints?

Pain:

Numbness:

Loss of strength:

5. Where do you feel most of the pain?

Neck:

Shoulder:

Arm:

Back:

Buttocks:

Leg:

6. Was there a cause for the beginning of your complaints?

7. Have your complaints occured slowly without any reason?

8. Pain occurs during

Lying:

Sitting:

Staying:

Walking:

Turning:

Bending over:

Lifting:

other activities:

9. Most of the complaints occur during

Lying:

Sitting:

Staying:

Walking:

Turning:

Bending over:

Lifting:

other activities:

10. Coughing, sneezing or pressing worsens the pain

other activities:

11. Has a diagnosis been made? If yes, which?

12. Have there been any imaging examinations?

13. Do you suffer from diabetes mellitus?

14. Have you ever undergone spine surgery? If yes, which kind of surgery and what was the result?

15. Which further treatments have been made to eliminate your complaints and what was the result?

16. Other information:

17. Do you want a cost estimate?